Child and Adolescent
Anxiety Disorders: Keeping
Calm with Kids
Mark A. Reinecke, Ph.D.
Northwestern University
SASED
Northern Illinois University
Naperville, IL.
February 28, 2014
COI Disclosure

Brian Harty Foundation

HRSA – GPE Psychology Training Grant (PI)
We’re Living in a Worried World
Every life has it’s share of anxiety, worry, fear
and dread…
Unemployment
Terrorism
Deficit & Financial Security
Saving for Retirement
Global Warming
Worries In Everyday Life
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Scheduling activities for 3 kids
Bullying at school
How will my son do on the ACT?
Credit card debt
Sick pet
My hot water heater died
Caring for grandparents
Chronic illness
My son shags cigarettes…is he drinking?
Empty nest…kids leaving
Boomerang…kids returning
Twenty Lessons
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Lesson #1
Lesson #2
Lesson #3
Lesson #4
Lesson #5
Lesson #6
Lesson #7
Lesson #8
Lesson #9
Lesson #10
Lesson #11
Lesson #12
Lesson #13
Lesson #14
Lesson #15
Lesson #16
Lesson #17
Lesson #18
Lesson #19
Lesson #20
Anxiety…it works
Anxiety—The Big A
We overestimate risk when we’re afraid
The future is uncertain
Influence and control
You have the power to control the level of anxiety you feel
Perfect solutions don’t exist
Sometimes bad things are controllable; sometimes not.
Intrusive thoughts are normal. It’s the meaning that counts.
Dwelling on problems impairs one’s ability to cope.
Worrying is highly over rated.
Do not magnify the importance of your physical sensations
It’s time to relax
Evaluate your thoughts themselves
Changing your thoughts
Avoiding problems is among the worst things one can do.
Social Anxiety – Worrying a bit too much what others think
What’s really on your mind?
Flow with the current of life
Live wisely
Lesson 1.
Anxiety…It Works
What exactly is anxiety?
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Based in Limbic system
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A normal, highly adaptive emotional state
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Facilitates response to a perceived threat
A Plate with C. Elegans
Sydney Brenner, D.Phil
South
African biologist
Worked
Now
at CRC, Cambridge University
at Salk Institute
Nobel
Prize in 2002
Established
C. Elegans as a model
organism to study genetics and cell
development.
First Complete Genetic Map
100 million base pairs
~20,000 genes
A Simple Nervous System
Nervous system consists of 302 neurons that form a small-world network
Their interconnections have been completely mapped out
C. Elegans
Lesson 2.
Anxiety…The “Big A”
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Anxiety has 4 components
1.
2.
3.
4.
Affect
Physiological
Cognitive
Behavioral
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Organizes perception, memory, & action
What Do Children Worry About?
Five Factor Model (Ollendick, 1983)
1.
2.
3.
4.
5.
Failure & Criticism
Unknown
Injury & Small Animals
Danger & Death
Medical Fears
Child Psychoeducation – Anxiety
Parent Psychoeducation - Anxiety
Developmentally Appropriate
Fears
1.
Infancy: Separation, strangers
2.
Early childhood: Loud noises, dark, doctors, animal
3.
Middle childhood: Frightening events (Scary
movies)
4.
Adolescence: New experiences, social rejection
Parent Psychoeducation - Anxiety
Child Psychoeducation - Anxiety
Normal Fears of Childhood
Normal Fears of Teens
Epidemiology
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5-18% of all children and adolescents
80% of adults with anxiety disorders report
anxiety symptoms prior to 18 yrs
High levels of comorbidity
Increased risk of anxiety, substance abuse,
and depression in adulthood
Impaired academic, social, family functioning
DSM-IV Anxiety Disorders
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Obsessive-Compulsive Disorder (OCD)
Generalized Anxiety Disorder (GAD)
Post Traumatic Stress Disorder (PTSD)
Panic Disorder
Separation Anxiety Disorder
Social Phobia, Social Anxiety
Simple Phobia
Atypical Anxiety Disorder (School Phobia?)
Serious Anxiety is Common
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GAD
Social Anxiety
Selective Mutism
Specific Phobias
Separation Anxiety
Panic
PTSD
OCD
2-5%
3-18%
>1%
3-20%
3-5%
1%
6%
1-4%
Comorbidity:
Number of diagnoses
in an anxiety disordered sample
45
40
35
30
25
20
15
10
5
0
One
Two
Three
Four
Of 106 consecutive cases (%)
Five
Etiology and Maintenance
Etiology
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Genetics
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Environment
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Temperament (shy, inhibited, risk averse)
Parent Psychoeducation - Anxiety
Heritability of Psychiatric Disorders
Heritability
Psychiatric Disorder
Zero
20-40%
Other conditions
Language, Religion
Anxiety, Depression
Bulimia
Myocardial Infarction
Breast Cancer, Hip
Fracture, Personality
40-60%
Alcohol, Drug Dependence
Blood Pressure, Adult
Onset Diabetes,
Plasma Cholesterol,
Asthma
60-80%
Schizophrenia, Bipolar Disorder
Weight, Bone Density
80-100%
Autism
Height, Brain Volume
Brain Metabolism in OCD
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Basal Ganglia
(Caudate)
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R. Anterior Cingulate
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R Orbitofrontal Cortex
The Essence of Anxiety
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Fearful Anticipation
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Rumination, Worry
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Vigilance
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Autonomic Arousal
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Avoidance
Parent Psychoeducation - Anxiety
The Anxious Individual
Cognitive contents incorporate themes of
danger and vulnerability. They view the
world as a dangerous place, and feel
incapable of preventing or managing these
risks. Threats may be physical, social, or
psychological. Anxiety serves an adaptive
function in preparing the individual to avoid
threat.
Parent Psychoeducation - Anxiety
Anxious Children Tend To:
1. Experience their moods more intensely
2. Demonstrate poor affect regulation
3. Feel they are unable to manage situations
4. Show inappropriate emotional expression
5. Be viewed as labile, inflexible, negative
Parents, Parenting & Child Anxiety
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Family/parenting styles (inconsistent findings)
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Mothers (intrusive involvement in situations with
negative affect)
(Hudson, Comer & Kendall, 2008)
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Fathers (limited risk-taking play behavior;
unpredictable, punitive, explosive)
(Bogels et al, 2007; Hughes, Furr, Sood, Barmish, &
Kendall, 2009)
Learning Theories
1.
Classical conditioning (E/RP)
2.
Operant conditioning (Contingency
management)
3.
Vicarious or observational learning
(modeling)
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Use all three in formulating and treating
Assessment
Making the Diagnosis
 K-SADS-PL
 Anxiety
Disorders Interview
Schedule for DSM-IV (ADIS-C/P)
Assessing Fears and Anxieties
Observational Methods
 Behavioral
Avoidance Tests
(BATs)
 Parent
/ Teacher / Clinician
Ratings
Monitoring - Anxiety
Assessing Fears and Anxieties
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Think-aloud procedures
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Thought-listing procedures
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Cartoons with “thought bubbles”
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Fear Thermometer
Self-Monitoring -Anxiety
Assessing Fears and Anxieties
Physiological Methods
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Heart rate
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Sweat index
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Respiration
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Finger pulse volume
Monitoring - Anxiety
Assessing Fears and Anxieties
-Self Report Methods
Fear Survey Schedule for Children (FSSC)
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Scale for Child Anxiety Related Emotional
Disorders (SCARED)
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Social Phobia and Anxiety Inventory for Children
(SPAI-C)
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Negative Affectivity Self-Statement Questionnaire
(NASSQ)
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Spence Children’s Anxiety Scale (SCAS)
Monitoring - Anxiety
Assessment Instrument
Our Favorites
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Multidimensional Anxiety Scale for
Children (MASC)
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Pediatric Anxiety Rating Scale (PARS)
Monitoring - Anxiety
Treatment Techniques &
Strategies
William James
“The first fact for us…
is that some form of
thinking goes on.”
Milton
“The mind is its own
place, and in itself, can
make a Heaven of Hell
and a Hell of Heaven.”
William Shakespeare
“There is nothing either
good or bad, but
thinking makes it so.”
Hamlet
Act II, Scene II
Assumptions of Cognitive
Therapy
5. Cognitive Specificity Hypothesis: Moods
and clinical disorders may be distinguished
on the basis of cognitive contents and
processes.
 If you change cognitions, one can manage
anxiety
Cognitive Concomitants of
Anxiety
1.
2.
3.
4.
5.
6.
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Increased Vigilance
Hypersensitivity to Threat Cues
Appraisal of Situations as Threatening
Overlook Safety Cues
High Standard for Security or “Guarantees”
Threat-Related Imagery
These are the targets of treatment
Cognitive Therapy in Practice
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Time limited, brief
Problem-oriented, focused, strategic
Collaborative therapeutic relationship
Empirically-based, “Personal Scientist”
Structured, active (agenda, homework)
Clear & consistent focus on cognitive
contents and processes, skills.
Lesson 3.
We Overestimate Risk When
We Are Afraid
ƒ (impending threat) (impaired coping)
Anxiety=
The specific nature of the fear will differ
depending upon the perceived threat.
Cognitive Formulation
-Salkovskis
Increased estimate of likelihood
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Increased estimate of “awfulness”
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Increased perception of responsibility
Lesson 4.
The Future is Uncertain
1. The hardest lesson of all
2. However much we would like a guarantee,
we can’t have it
3. To feel secure, we must accept ambiguity
Lesson 5.
Influence and Control
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Increased estimate of likelihood
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Increased estimate of “awfulness”
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Increased perception of responsibility
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Control exists on a continuum of
“degrees of influence”
Lesson 5.
Influence and Control
Lesson 7.
Perfectionism
Do you believe…
 For every problem there is a single, best
solution?
 There’s always room for improvement?
 Perfection can and should be pursued, no
matter what the cost?
 One should expect the best, and settle for
nothing less?
Maniacal Perfectionism
"I'm a maniacal perfectionist. And if I weren't, I
wouldn't have this company. .. It's the best rap!
Nobody's going to fault me for that. I have proven
that being a perfectionist can be profitable and
admirable when creating content across the board:
in television, books, newspapers, radio, videos. ..
All that content is impeccable."
Martha Stewart (2000)
Being Imperfect…
is highly desirable
“Trying to be perfect may be sort of inevitable for
people like us, who are smart and ambitious and
interested in the world and in its good opinion. At one
level it's too hard, and at another, it's too cheap and
easy. It requires you mainly to read the zeitgeist of
wherever and whenever you happen to be…and be the
best of whatever the zeitgeist dictates or requires.
When you're clever you can read them and do the
imitation required. But nothing important, or meaningful,
or beautiful, or interesting, or great ever came out of
imitations. The thing that is really hard, and really
amazing, is giving up on being perfect and beginning
the work of becoming yourself.
Anna Quindlen (1999)
Lesson 7.
Perfect Solutions Don’t Exist
•
Perfect doesn’t exist, conceptually or in
practice
•
Perfectionism is highly correlated with both
depression and anxiety
•
Failure to meet “ideal” standards is associated
with stress and guilt
•
In a changing world, flexibility and creativity are
more valuable than a relentless pursuit of
perfection
Lesson 8.
Sometimes You Can Take Control…
“I should have seen this coming”
“If only I had ____, we’d be OK”
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Perceptions of responsibility and control are
linked to mood
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Did I actually cause this event?
Did other factors contribute?
How much “influence” do I actually have?
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Lesson 9.
Don’t Dwell on That…
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Rumination is common
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Content of thoughts similar in anxious and
non-anxious individuals
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Secondary cognitions differ
What Can Be Done?
1. Mindful Acceptance
“It’s just a thought”
2. Rational Disputation
Challenge the secondary cognition
3. Desensitization
Schedule Rumination…30 minutes a day
What’s the solution?
Lesson 14.
Evaluate Your Thoughts & Make
Then Give Good Account of
Themselves
1. What’s the evidence?
2. Is there another, more adaptive, way of
looking at this?
3. So what?
a) Decatastrophize everything. Is it really that big
of a deal?
b) What can be done?
Downward Arrow
1. If I don’t get into Yale, it would be
catastrophic!
2.
3.
4.
5.
6.
7.
OCD-Intrusive Thoughts
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Negative intrusive thoughts are common.
Intrusive thoughts are experienced by 90% of
individuals (Rachman & DeSilva, 1978).
The content of intrusive thoughts does not
distinguish patients with OCD.
Appraisals of thoughts and beliefs about the
need to control negative thoughts does
distinguish patients with OCD.
Caregiver Psychoeducation
Steven King
Oh no! I’ve got to stop
thinking that!
vs.
Buckets of blood at the
prom. Cool! I’ll write a
screen play!
Appraisal in OCD
Individuals with OCD perceive their
thoughts as:
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more distressing
more uncontrollable
less acceptable
more important
These appraisals serve as clinical
targets.
Intrusive Thoughts
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You just can’t stop the
flying monkeys!
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Hail Dorothy!
CBT principals for OCD
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Basis for CBT is same for children as adults
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Exposure – facing the fear, trigger obsessive
thoughts and anxiety
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Response prevention – not performing the ritual
that decreases anxiety after the exposure;
preventing compulsive rituals
Exposure, Activity Selection, Relaxation
How I Ran OCD Off My Land
March, Mulle, & Herbal (1994)
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Four Stages, 16 session protocol
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Session 1: Neurobehavioral Model
Session 2: Make OCD the problem
Session 3: Mapping OCD
Sessions 4-12: Exposure
Caregiver Psychoeducation,
Monitoring, Exposure
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Temple “FEAR” Program
F
Feeling frightened?
Monitor
E
Expecting bad things?
Cognitions
A
Attitudes & Actions.
Coping
R
Results & Rewards
Reinforce
Kendall’s “Coping Cat”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Build rapport, socialize to treatment
Identify feelings, distinguish anxiety
Identify somatic responses (F-step)
Parent session
Relaxation exercises, monitor tension
Identify thoughts, self talk (E-step)
Relaxation and cognitive change (A-step)
Self-rating performance, reward (R-step)
Parent session
Practice FEAR
Lesson 19.
Flow With the Current of Life
“By letting it go, it all gets done…
But when you try and try, the world is
beyond winning.”
Lao Tsu
Go With The Flow of the River
Be Like a Stick
Lesson 20.
Live Wisely
•
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•
•
•
•
•
•
Judicious use of knowledge
Open minded
Altruistic, empathic
Compassion
Self-reflection
Insight
Tolerance
Awareness of larger issues
The Road to Wisdom
Keep Calm and Carry On
Summary…
What Works
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Keep in mind that anxiety works for you
Think clearly. Keep problems in perspective
Approach the things you fear
Exposure, exposure, and more exposure
Active problem solving, solution-focused
thinking
Balance active coping with mindful
acceptance
Take the long view, the larger view
Live with faith, hope, and equanimity
Components of Effective
Treatment
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Psychoeducation
Relaxation
Behavior management (reinforcement)
Modeling
Problem Solving
Exposure
Behavioral Treatments
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Develop fear hierarchy
Relaxation / Breathing / Pleasant Imagery
Modeling
Systematic Desensitization
Prolonged Exposure, Flooding
Contingency Management
Self-Management
Combined
Cognitive: Anxiety, Modeling,
Self Monitoring, Exposure
CBT Tool Kit
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Develop fear hierarchy
Exposure
Self –monitoring (Fear thermometer)
Problem solving
Rational Disputation; Adaptive SelfStatements
Contingency management
Cognitive: Anxiety, Exposure,
Modeling, Relaxation, SelfMonitoring
Clinical Outcomes
An Empirically-Supported Approach
Kendall (1994)
First RCT of CBT with Anxious Youth
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N=47 9-13 years old
CBT vs. Wait List Control
Treatment: 16 sessions of Coping Cat
Respondents: Self-report, parent, teacher
Measures: ADIS, RCMAS, STAIC, FSSC-R
Clinically significant improvement; Diagnosis
free at 1 year follow-up: 60% vs. 10%
JCCP. (1994), 62: 100-110.
Kendall et al. (1997)
Follow-Up
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CBT vs. Wait List Control
Treatment: 16 sessions of Coping Cat
Respondents: Self-report, parent, teacher
Measures: ADIS, RCMAS, STAIC, FSSC-R
Clinically significant improvement; Diagnosis
free at 1 year follow-up: 71% vs. 7%
JCCP (1997), 65: 366-380.
CBT for OCD
Probably a “Well Established” Treatment”
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March et al (1994)
Piacentini et al. (1994)
Knox et al. (1996)
Scahill et al. (1996)
Weever et al. (1997)
Fischer et al. (1998)
Franklin et al. (1998)
Thienemann et al. (2001)
Waters et al. (2001)
Piacentini et al. (1999, 2002)
n=15
n=3
n=4
n=7
n=57
n=15
n=14
n=18
n=7
n=42
open trial
open trial
open trial
open trial
open trial
open trial
open trial
open trial
open trial
open trial
POTS
Pediatric OCD Treatment Study
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CBT; Sertraline (Zoloft); Combo; PBO
N=112 7-17 years old
Measure: YBOCS
Multisite, double blind PBO controlled
 Results: 12 week Combo >CBT=Ser >PBO
 Remission: Combo: 54%; CBT: 40%; Ser: 21%; PBO: 4%
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POTS Team (2004). Cognitive-behavior therapy, Sertraline, and
their combination for children and adolescents with obsessivecompulsive disorder. JAMA , 292: 1969-1976.
CAMS: Drop Out by Treatment
Condition
Treatment Condition
Completed Study
Dropped Out
Total
COMB
SRT
CBT
PBO
128
112
134
61
12
21
5
15
15.8%
3.6%
19.7%
133
139
76
8.6%
140
CAMS: Treatment Response
100%
81%
80%
60%
60%
55%
40%
24%
20%
0%
COMB
CBT
SRT
% Responder
PBO
CAMS: PARS Improvement
25
20
15
10
5
0
WK 0
WK 4
COMB
WK 8
SRT
CBT
WK 12
PBO
Does CBT Work?
Compton et al. (2004)

Review of 21 RCT’s of CBT for childhood
depression and anxiety indicates that CBT “is
currently the treatment of choice”

Medium to large effects relative to waitlist,
inactive control, active control
JAACAP (2004) 43: 930-959
Does CBT Work?
Cartwright-Hatton et al. (2004)

Review of 10 RCT’s of CBT for child and
adolescent anxiety indicates CBT is effective
compared to no-treatment control.

Remission rate: 56.5% (CBT) vs. 34.8%
(control)
Brit. J. Clin. Psych., 43: 421-436.
What Enhances Improvement?

Child involvement
(Chu & Kendall, 2004; Braswell, et al, 1985)

Therapist “relationship building” strategies
(Creed & Kendall, 2005)

Therapist flexibility (associated with increased child
involvement) (Kendall & Chu, 2000)
What Truly Matters
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Assessment
Guided discovery
Involvement
Cooperative, collaborative rapport
Relapse prevention
Planning for generalization
Arranging termination
Individualizing the program
Therapist flexibility (with fidelity)
What Not To Do
(Kendall)
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Teachy-preachy style
Forcing youth to talk about feelings
Excessive focus on tasks
Mechanical self-talk
Tension and upset about scheduling
Aversive context (interpersonal conflicts and
oppositionality)

“Wimpy” role-plays or exposure tasks
What we don’t know

Proper role for parents in treatment

Mechanisms of change

How to help treatment nonresponders

Active components of the program

Effective methods for dissemination
Keep Calm and Carry On
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www.keepcalmthebook.com

www.amazon.com

www.newharbinger.com