High Incidence Condition Presentation: Anxiety Disorders

1. Presented by Chloe Ruebeck University of Utah May 05, 2009 High Incidence Condition Presentation:Anxiety Disorders Training School Psychologists to be Experts in Evidence Based Practice for Tertiary Students with Serious Emotional Disturbance/Behavioral Disorders Department of Educational Psychology School Psychology Program US Office of Education 84.325K H325K080308

2. Common Anxiety Disorders in Youth • Generalized Anxiety Disorder (GAD) • Obsessive Compulsive Disorder (OCD) • Social Phobia/School Phobia • Panic Attacks (among Adolescents)

3. DSM-IV-TR Diagnostic Criteria for 300.02 General Anxiety Disorder (Includes Overanxious Disorder of Childhood) A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).  B. The person finds it difficult to control the worry.  C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one of the following items is required in children.   (1) restlessness or feeling keyed up or on edge 
(2) being easily fatigued 
(3) difficulty concentrating or mind going blank 
(4) irritability 
(5) muscle tension 
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) 

4. General Anxiety Disorder: DSM-IV-TR Cont. D. The focus of the anxiety and worry is not confined to features of an Axis I disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

5. Special Considerations • This disorder is highly developmentally linked, many fears and anxieties may be outgrown. • Anxiety is a highly comorbid disorder with behavioral disorders, depression, substance abuse and other anxiety disorders; comorbidity rates ranging from 65-84% in epidemiological and clinical samples (Bird, Gould, & Staghezza, 1993; Albano, Chorpita, Barlow, 2003) . • There are three considerations that should be taken into account when diagnosing. First, is the anxiety produced by an actual threat, then the youth’s developmental context, and lastly the degree of impairment. • There are two types of anxieties, state and trait. State anxiety can occur in certain situations and trait anxiety is more stable occurring across situations (Cattell & Schier, 1961, 1963) • Anxiety can cause significant school problems for children both academically and socially (Ginsburg & Silverman, 1996)

6. History of Anxiety • Psychologists have struggled to understand what causes anxiety, since the birth of modern psychology. • For example, Freud’s early work focused on childhood anxiety (Little Hans). • Most of the theories come from a behavioral cognitive standpoint, that believes that fears can be both learned and unlearned. • One of the best know examples in support of this theory, is the study of Little Albert by John Watson in 1920.

7. Cause/Contributory Factors • According to Gray’s Model, the Behavioral Inhibition System (BIS) causes anxiety. Anxiety symptoms occur when the Comparator subsystem of the BIS predicts an aversive or unmatching future event (1982). • Many of these aversive ideas come from individuals’ schemas. These schemas are usually established early in development. A number of theories for this acquisition are; “preparedness” (Seligman, 1970,1971), two-factor theory (Mowrer, 1939), approach-withdrawal theory (Delprato & McGlynn, 1984) and social learning theory (Bandura, 1977). • Some of the causes of these negative schemas are academic performance, situational variables in the family or at school, stress and pressure, perceived or real expectations by self or others, and degree of success in social and academic situations (Huberty, 45-52). • Genetics also plays a role in anxious youth. Children of anxiety disordered mothers are more likely to have anxiety. Another factor that contributes to this, is modeling (Last, Hersen, Kazdin, Francis, & Grubb, 1987).

8. EBP Assessment Procedures for Anxiety • Behavior Rating Scales • Direct Observations • Functional Behavior Assessments • Parent/Child Interview

9. EBP Assessment ProceduresBehavioral Rating Scales/Checklists: • Beck Anxiety Inventory (BAI) • Behavior Assessment Scale for Children-II (BASC) • Child Behavior Checklist (CBCL) • Revised Children’s Manifest Anxiety Scale (RCMAS) • Millon Adolescent Clinical Inventory (MACI) • Minnesota Multiphasic Personality Inventory-II (MMPI-2) • Multidimensional Anxiety Scale for Children (MASC)

10. EBP Reviews Barrios and O’Dell’s Review (1998) Chorpita and Colleague’s Review (2002) Silverman, Pina and Viswesvaran (2008)

11. EBP Treatment/Interventions(Chorpita, B.F., & Southam-Gerow. M.A. (2006). Fears and Anxieties. In Eric J. Mash & Russell A. Barkley, Treatment of Childhood Disorders, Third Edition (pp. 271-335). New York, NY: The Guilford Press. ) Exposure • In vivo or direct exposure • In vitro or imagined exposure • Graduated exposure • Systematic Desensitization- relaxation training with subsequent graduated exposure trials • Implosion- rehearsal of a feared stimulus or event, with added meaning presented by the therapist

12. EBP Treatment/Intervention Cont. Modeling • Live Modeling- watching a person successfully interact with a feared stimulus • Symbolic Modeling- through video or in a photograph • Covert Modeling- imagine the model interacting with feared stimulus • Participant Modeling- First asked to watch and then to perform the same behaviors as the model

13. EBP Treatment/Intervention Cont. Cognitive Techniques • Cognitive-behavioral therapy (e.g., Barrett, Dadds, & Rapee, 1996; Kendall et al., 1997) • Self-management or Self-talk • Cognitive restructuring- first identify negative self-talk and then the therapist can replace it with a more adaptive ones • Attributional retraining- a child is asked to distinguish his or her attributions to many situations, the therapist can then introduce alternative attributions and they can test them out for efficacy

14. EBP Treatment/Intervention Cont. Other Effective Techniques • Emotion Skills Training- recognize, label and self-monitor • Relaxation Training • Contingency Management (typically paired with exposure) • Self-monitoring • Problem-solving Training • Medications- SSRIs (fluvoxamine, fluoxetine, sertraline, clomipramine-most effective for OCD)

15. Fads and Non-EBP • Eye Movement Desensitization and Reprocessing (EMDR) Treatment for Post Traumatic Stress disorder by Dr. Francine Shapiro

16. Recent Intervention-Coping Cat for Generalized and Social Anxiety Disorders (Kendall, 2002) • A 16-20 cognitive-behavioral therapy session treatment package that includes both a skills training and exposure component, that is implemented in a small group format • First, they are taught the FEAR steps: Feeling frightened, Expecting bad things to happen, Actions and attitudes to take, and Results and rewards (first 8 sessions) • The specific steps are: • Recognizing anxious feelings and somatic reactions • The role of cognition and self-talk in exacerbating anxious situations • Using problem-solving and coping skills to manage anxiety • The use of self-evaluation and self-reinforcement strategies to help coping maintenance

17. Coping Cat Cont. • The remaining 8-12 sessions focus on tailoring coping plan’s for each child’s fears and anxieties, while implementing modeling, in vivo exposures, role plays, relaxation training, and contingent reinforcement • The Revised Children's Manifest Anxiety Scales (RCMAS) was used as the dependent measure along with a battery of other scales and interviews, children were given these scales at pre and post test • Parents and teachers were also asked to report anxiety symptoms using the CBCL • The parents reported that 71% of the children no longer had their primary anxiety disorder as their primary disorder and 51% no longer met criteria for their primary anxiety disorder at post-treatment (Kendall et. al., 1997).

18. Conclusions • A number of treatments have shown to be efficacious in reducing and treating anxiety related symptoms, moreover, a combination of interventions may be the most effective in treating children with anxiety disorder. • Eisenberg, Cumberland, and Spinrad (1998), suggest that getting the parents involved in treatment and encouraging them to talk to their children, accept them and be supportive could help improve their emotional competence.

19. References • Albano, A.M., Chorpita, B.F., & Barlow, D.H. (2003). Childhood anxiety disorders. In E.J. Mash & R.A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 279-329). New York: Guilford Press. • Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. • Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333–342. • Bird, H.R., Gould, M.S., & Staghezza, B. M. (1993). Patterns of diagnostic comorbidity in a community sample of children aged 9 through 16 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (4), 415-423. • Chorpita, B.F., & Southam-Gerow. M.A. (2006). Fears and Anxieties. In Eric J. Mash & Russell A. Barkley, Treatment of Childhood Disorders, Third Edition (pp. 271-335). New York, NY: The Guilford Press. • Delprato, D.J., & McGlynn, F. D. (1984). Behavioral theories of anxiety disorders. In S. M. Turner (Ed.), Behavioral theories and treatment of anxiety (pp. 1-49). New York: Plenum Press. • Eisenberg, N., Cumberland, A., & Spinrad, T. (1998). Parental socialization of emotion. Psychological Inquiry, 9, 241–273.

20. References • Ginsburg, G. S., & Silverman, W. K. (1996). Phobic and anxiety disorders in Hispanic and Caucasian youth. Journal of Anxiety Disorders, 10, 517–528. • http://www.emdr.com/briefdes.htm • Huberty, T. Children and Anxiety • Kendall, P. C. (2002). Coping Cat therapist manual. Ardmore, PA: Workbook. • Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam- Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65, 366 –380. • Last, C. G., Hersen, M., Kazdin, A. E., Francis, G., & Grubb, H. J. (1987). Psychiatric illness in the mothers of anxious children. American Journal of Psychiatry, 144, 1580 –1583. • Mowrer, O.H. (1939). A stimulus-response analysis of anxiety and its role as a reinforcing agent. Psychological Review, 46, 553-565. • Seligman, M.E.P. (1970). On the generality of the laws of learning. Psychological Review, 77, 406-418.

21. References • Silverman, W.K., Pina, A.A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37, 105-130. • Suveg, C., Sood, E., Barmish, A., Tiwari, S., Hudson, J., & Kendall, P. (2008, December). 'I'd rather not talk about it': Emotion parenting in families of children with an anxiety disorder. Journal of Family Psychology, 22(6), 875-884. • Watson, J.B., & Rayner R. (1920). Conditioned emotional responses. Journal of Experimental Psychology, 3, 1-14.