The Treatment of Childhood Anxiety

Wednesday 5th March 201410:30am - 12pm AEDT

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PRESENTERS:Prof Ronald M Rapee

Centre for Emotional HealthMacquarie University

Carol WoolcockChild and Adolescent Psychotherapist and

Social Worker

Facilitator: Harry Lovelock, Senior Executive Manager APS

Treatment of anxiety in young children

Ronald M RapeeCentre for Emotional Health

Macquarie University

Who is this treatment for?• Children with a clinical anxiety disorder

– 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

JAMES ET AL (2005) CARTWRIGHT-HATTON ET AL, 2004

%

DX-FREE

Meta-analyses of treatments for child anxiety

CBT vs control non-CBT vs control

CBT vs Passive control

CBT vs Active control

00.10.20.30.40.50.60.70.80.9

Reynolds et al 2012

Note – Child self report

E.S

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 PLACEBOHUDSON ET AL (2009)• 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

GCBT GSA0

102030405060708090

100

PrePost3monthFU

% no longer meeting criteria for primary anxiety disorder

Primary Anxiety Disorder

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 child-

minding, time)• Step parents, separated?

The Cool Kids ProgramContent

• 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

• 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 2

• 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

Cool Kids Program – Session outline 3

An exampleExposure 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

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 dinnerSTEP 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 afternoonReward: 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 eveningReward: 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 eveningReward: 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. Psychoeducation and motivation2. Management of parent overprotection3. Graded exposure to child’s fears4. 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 ClinicPHONE: 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

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 sessions1. Establish contract with James2. Relaxation techniques3. Establish hierarchy of fears4. Introduce drawings & photos of least feared5. Introduce drawings & photos of most feared6. 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• 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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