Comorbidity of childhood balance and anxiety disorders: treatment and theory Ph.D. study by Orit Erez.

Comorbidity of childhood balance and anxiety disorders: treatment

and theory

Ph.D. study by Orit Erez

Comorbidity of balance and anxiety disorders

A recent special issue of the J. of Anxiety Disorders, reviewed the experimental and clinical findings related to comorbidity of balance disorders and anxiety (Sklare et al., 2001).

Comorbidity of balance and anxiety disorders Causality ????

Balance

disorder

Anxiety

disorder

Balance

disorder

~

~

Anxiety

disorder

Balance

disorder

Anxiety

disorder

We are interested in this option

Balance disorder as the origin of balance and anxiety comorbidity

Theoretical implication: Anxiety evolves from normal limbic system that responds excessively to interaction with deficient balance system.

Clinical implication: Successful balance treatment may ameliorate also the anxiety symptoms.

Checking for comorbidity in childhood

In children with anxiety as primary disorder.

In children with balance as primary disorder.

Comorbidity with anxiety as primary disorder

Is childhood anxiety associated with poor balance performance ?

( Erez et al., J. of Anxiety Disorders, 2003)

Subjects

Group Origin Diagnosis of anxiety

Age (yrsSEM)

Gender (F/M)

Anxiety (n=20)

Ambulatory clinic

Separation (n=11) Generalized (n=7) PTSD (n=1) Phobias (n=1)

10.20.38 (7-14)

8/12

Control (n=20)

Normal class children

10.60.36 (7-13)

8/12

Exclusion criteria: no past history of acute vestibular disorder or chronic ear disease.

Procedure in chronological order: DSM-IV based diagnosis of anxiety disorder by a

psychiatrist. Elevated anxiety confirmed on Fear Survey

Schedule for Children (FSSC; Ollendick, 1983). Neurological and neuro-otological examination by

a neurologist. Static and dynamic balance tests by a movement

therapist (Orit Erez). Dizziness & motion sickness questionnaires.

Results

Children with anxiety disorders vs. controls:

Reported more dizziness episodes (80 vs. 40%). Reported enhanced sensitivity to motion sickness

provoking situations. Were hypersensitive to the rotary chair test.

Children with anxiety disorders had more balance mistakes relative to controls

*p<0.05; **p<0.01; ***p<0.001

TestManipulation effectGroup effect

Interaction

G by M

Standheel-to-toe

Floor-bench ns Eyes open-closed **

nsnsns

Stand on one-foot

Floor-bench-trampoline *** Eyes open-closed ***

ns*ns

Stand on cylinder

Head still-nodding * *ns

Walk oncubicles

Eyes open-closed *** nsns

Walk onrope

Normal-heel-to-toe ***Eyes open-closed ***

*ns*

Time to task completion was longer in children with anxiety disorders relative to

controls

TestManipulation effectGroupEffect

Interaction

G by M

Walk oncubicles

Eyes open-closed ***nsns

Walk onrope

Bench-rope **Normal-heel-to-toe *** Eyes open-closed ***(Surface by Walking)

*nsnsns*

Walk onrope

Spinning straight-bent ns**ns

*p<0.05; **p<0.01; ***p<0.001

Is childhood anxiety associated with poor balance performance ?

Yes !!!

Comorbidity with balance as primary disorder

Are children with poor balance performance more anxious than normal controls?

Thesis by Moran Levin (2004)

Subjects

N ♂/♀ Age (yrs±SE

M

Age range (yrs)

Clinical Referred to OT for balance treatment

35 26/9 5.8±0.10 5.0-7.3

Control Normal class children

25 15/10 5.8±0.15 5.0-7.3

Inclusion criteria in clinical group:< normal balance performance (Bruininks 1978).Normal schooling system.

Inclusion criteria in control group:No known balance difficulties.

Exclusion criteria:Tactile difficulties (Royeen & Fortune, 1990).Previous psychological or occupational therapies.No other major developmental problems.

Procedure in chronological order:Balance and anxiety were assessed upon arrival

at the clinic.Controls were tested at the school. Testing and treatment were administered by a

certified occupational therapist, experienced in

sensory integration techniques (Moran Meidan).

Balance tests: Balance sub-test of the Bruninks-Oseretsky Test of

Motor Proficiency (Bruninks, 1978).Vestibular scale of The Parental Sensory Profile

Assessment (Dunn, 1999).

Anxiety tests:Anxiety-Depression Parental Scale of the Child

Behavior Checklist (CBCL; Achenbach, 1991).Fear Survey Schedule for Children – self report

(FSSC; Ollendick, 1983).

Obvious result:

Clinical < Controls on balance tests; p<.001.

New result:

Clinical > Controls on anxiety tests; p<.001.

Relation between parental report on balance and emotionality

10

20

30

40

50

60

0 10 20 30

Anxiety - Depression (CBCL)

Ve

sti

bu

lar

Sc

ale

(D

un

n) Clinical

Control

r=-.32

r=-.52*

Relation between balance performance and parental report on emotionality

0

5

10

15

20

25

30

0 10 20 30

Anxiety - Depression (CBCL)

Bal

ance

(B

run

inks

) Clinical

Control

r=.03

r=-.72*

Relation between parental report on balance and self report on emotionality

10

20

30

40

50

60

100 125 150 175 200 225

Fear Survey (FSSC)

Ve

stib

ula

r S

cale

(D

un

n)

Clinical

Controlr=.14

r=-.31

Relation between balance performance and self report on emotionality

0

5

10

15

20

25

30

100 125 150 175 200 225

Fear Survey (FSSC)

Ba

lan

ce

(B

run

ink

s)

Clinical

Control

r=-.52*

r=-.63*

Are children with poor balance performance more anxious than normal controls?

Yes !!!

Treatment of children with balance as primary disorder

and elevated anxiety

Can balance treatment alleviate the anxiety?

Thesis by Einat Karmon-Weisman (2004)

Subjects

N ♂/♀ Age (yrs±SE

M

Age range (yrs)

Treated Referred to OT for balance treatment

25 22/3 5.4±0.08 5.0-6.1

Non-treated

Waiting list of similarly referred children

24 21/3 5.4±0.09 5.0-6.1

Inclusion criteria:< normal balance performance (Bruininks 1978).> normal self report on Fear Survey (Ollendick, 1983).

Normal schooling system.

Exclusion criteria:Tactile difficulties (Royeen & Fortune, 1990).Previous psychological or occupational therapies.No other major developmental problems.

Procedure in chronological order:Balance and anxiety were assessed upon arrival at the clinic.Half of the children received 12 weekly sessions of OT with

sensory-motor orientation:

Improvement of flexor and tensor muscle tone.

Maintenance of balance in different postures.

Vestibular stim in various positions, speeds & intensities.Balance and anxiety were reassessed after the last treatment.Testing and treatment were administered by a certified

occupational therapist, experienced in sensory integration

techniques (Einat Veisman-Carmon).

Balance tests: Balance sub-test of the Bruninks-Oseretsky Test of

Motor Proficiency (Bruninks, 1978).Vestibular scale of The Parental Sensory Profile

Assessment (Dunn, 1999).

Anxiety tests:Anxiety-Depression Parental Scale of the Child

Behavior Checklist (CBCL; Achenbach, 1991).Fear Survey Schedule for Children – self report

(FSSC; Ollendick, 1983).

Balance(Bruninks-Oseretsky Test of Motor Proficiency)

12

3456789

101112131415

After treatment

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Before treatment

Treatment

Control

Group by Time: p<.001

Vestibular Processing (Parental Report)

10

20

30

40

50

After treatmentBefore treatment

0

10

20

30

40

Treatment

Control

Group by Time: p<.001

Anxiety Level(CBCL: Parental reports)

0.00

5.00

10.00

15.00

After treatment

0.00

5.00

10.00

15.00

Before treatment

Treatment

Control

Group by Time: p<.001

Anxiety Level(Fear Survey Schedule for Children: Child Report)

0

50

100

150

After treatment

0

50

100

150

Before treatment

Treatment

Control

Group by Time: p<.001

Can balance treatment alleviate the anxiety?

Yes !!!

Theoretical background:Normal individual facing an

aversive challenge

Two stage theory of learning predicts:

1st stage: Fast acquisition of fear response.

2nd stage: Slow acquisition of motor response.

Extension to three stage theory of learning:

3rd stage: Extinction of fear response after acquisition of motor response.

Theoretical background:Individual with balance disorder

facing balance challenging conditions

Three stage theory of learning predicts:

1st stage: Fast acquisition of fear response.

2nd stage: No acquisition of balance restoration motor response.

3rd stage: No extinction of fear response.

The next step: Treatment of children with anxiety as primary disorder and poor balance

Select a group of children with generalized or separation anxiety.

Test the group for comorbidity with balance deficiency.

Provide a 2-3 months physical balance training.

Test for improvement of balance skills.

Test for a short and long-term amelioration of anxiety symptoms.