The Treatment of Childhood
Anxiety
Wednesday 5th March 2014
10:30am - 12pm AEDT
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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
Treatment of anxiety in young
children
Ronald M Rapee
Centre for Emotional Health
Macquarie University
Who is this treatment for?
• Children with a clinical anxiety disorder
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–
–
–
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Separation anxiety
Social anxiety
Generalised anxiety
Obsessive compulsive
Phobias
• Anxiety is primary problem
• Out of proportion to age and context
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
REMISSION OF ANXIETY
DIAGNOSIS ACROSS ALL STUDIES
IN TWO REVIEWS
%
DXFREE
JAMES ET AL (2005)
CARTWRIGHT-HATTON ET AL, 2004
Meta-analyses of treatments for child anxiety
Reynolds et al 2012
1
0.8
E.S 0.6
0.4
0.2
0
CBT vs control
non-CBT vs
control
Note – Child self report
CBT vs Passive
control
CBT vs Active
control
A detailed example
the Cool Kids program
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
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
Does Cool Kids work?
COMPARISON WITH PLACEBO
HUDSON ET AL (2009)
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•
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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.
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
Primary Anxiety Disorder
100
% no longer
meeting
criteria for
primary
anxiety
disorder
90
80
70
60
Pre
50
Post
40
3monthFU
30
20
10
0
GCBT
GSA
Clinical Severity of Primary Anxiety Disorder
Clinical
Severity
Rating
Delivering treatment to children
aged 7-12
Who to include?
Principal diagnosis of anxiety (?)
Any anxiety disorder (PTSD?)
Aged 7 and up
Encourage both parents (need to consider childminding, time)
• Step parents, separated?
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•
•
•
The Cool Kids Program
Content
• Psycho-education
• Cognitive restructuring
(Detective thinking)
• Child management
• In vivo exposure (plus rewards)
• Skills training
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
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
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
An example
Exposure for separation fear
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
•
•
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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 day
Reward: Choose activity for Mum and I to do
STEP 5: Stay home with a sitter in the afternoon
Reward: Stay up a half-hour later than normal
STEP 6: Stay home with a sitter for the day
Reward: Mum will bring home a surprise
STEP 7: Stay home with Dad while Mum goes out for the evening
Reward: Have a friend over for dinner
STEP 8: Stay home with Grandma while Mum goes out till late at
night
Reward: Go to Dinner at a restaurant
STEP 9: Stay home with a sitter for a few hours in evening
Reward: Have a few friends over to sleep for night
STEP 10: Stay home with a sitter while Mum goes out for the night
Reward: Go to Sega World with two friends
Delivering treatment to children
aged 3-6
The Cool Little Kids program
Structure of sessions
• 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
Cool Little Kids – Session Outline
1.
2.
3.
4.
Psychoeducation and motivation
Management of parent overprotection
Graded exposure to child’s fears
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
Centre for
Emotional Health
Emotional Health Clinic
PHONE: 02/ 9850-8711
www.centreforemotionalhealth.com.au
I KNOW IT’S JUST THEIR HABITAT
BUT PLEASE DON’T BUG ME!
Treatment of a 9 year old boy
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
•
•
•
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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”
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
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
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
Overview of sessions
1.
2.
3.
4.
5.
6.
Establish contract with James
Relaxation techniques
Establish hierarchy of fears
Introduce drawings & photos of least feared
Introduce drawings & photos of most feared
Maintenance plan, celebration
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
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
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
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.
Session 3. Hierarchy of fears
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Establish list from least to most concerning
Ants
Beetles
Flies
Butterflies
Mosquitoes
Spiders
What is his fear about each one?
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.
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
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.
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
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
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?
CONSIDERATIONS
• A rehearsal of how he will negotiate the topic
with his teacher can be useful
• Allow the child to set the pace in respect to
replacing his plastic bugs or viewing live bugs
in a jar.
• Convey a healthy respect for venomous bugs
Concurrent intervention
• Discussion with parents re criticism by medical
team. Parents decided to arrange a meeting
with the team leader to voice their concerns,
particularly the negative impact on James.
• As the parents believe the criticism is
unfounded they would like the team leader to
convey to James how pleased his is with
James's efforts.
CONSIDERATIONS
• Often there is no clear cause for the
development of a phobia and assessment
should take into consideration not only child
factors but explore environmental factors and
family characteristics.
QUESTIONS &
ANSWERS
REMINDERS
•
Contact The ATAPS CMHS Clinical Support Service. Phone on
1800 031 185 or email clinicalsupport@psychology.org.au
•
Another webinar in 2 weeks time on the 19th March (1:30-3pm) The Treatment of Emotional Disorders in High Functioning
Autism. Two further CMH webinars will be organised in the coming
months – See the ATAPS Clinical Support Service web portal.
•
A recording of this webinar will be available on the APS ATAPS
Clinical Support Service web portal - see
http://www.psychology.org.au/ATAPS/networking_CMHS/
•
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•
Thank-you for your participation and we hope you enjoyed it.