The Society for Clinical Child and Adolescent Psychology (SCCAP): Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent Mental Health Problems With additional support from Florida International University and The Children’s Trust.
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The Society for Clinical Child and Adolescent Psychology (SCCAP):
Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent
Mental Health Problems
With additional support from Florida International University and The Children’s Trust.
Workshop Evidence-based Treatment for Child Anxiety Problems: Cognitive Behavioral Strategies
Wendy Silverman, Ph.D. Professor of Psychology and Director of Clinical Training
Director, Child Anxiety and Phobia Program Florida International University
Acknowledgments
FIU Faculty: Jim Jaccard, Bill Kurtines
Past Post docs: Steve Berman (UCF), Golda Ginsburg (Johns Hopkins), Brian Rabian (Penn State), Andreas Dick-Niederhauser (Bern, Switzerland)
Current Post docs: Carla Marin, Yasmin Rey
Current FIU graduate students: Ayce CiCi-Goltkun, Jessica Dahan, Cristina Del Busto, Irina Fredricks, Devi Hausman, Maria Pienkowski, Ileana Hernandez, Luci Motoca,
FIU undergraduate students
NIMH Research Grants: R29MH44781, R01MH49680, R21MH 54690, R01MH63997, R01 MH079943
NIMH Midcareer Development Award: K24MH73696
Additional Acknowledgments
Anne Marie Albano
CAMS Team (Golda Ginsburg)
Debbie Beidel
Eliot Goldman
Christopher Kearney
Phil Kendall
Ron Rapee
Tom Ollendick
Michael Southam-Gerow
The Reach Institute (Peter Jensen and colleagues)
Workshop Overview
Prevalence
Diagnosing and assessing
Etiological theories
Overview of treatment
Treatment nuts and bolts
Cases and questions
Background Information
Anxiety disorders of childhood and adolescence are one of the most, if not the most prevalent problems.
Most prevalent problems in adults.
PREVALENCE OF CHILD DISORDERS (ANDERSON ET AL. ,1987)
DIAGNOSIS PERCENT
OPPOSITIONAL 2.2 : 1 5.7
SEPARATION 3.5
CONDUCT 3.4
OVERANXIOUS 2.9
SIMPLE PHOBIA 0. 2.4
MOOD 1.8
SOCIAL PHOBIA 0.9
ALL CONDUCT 2.8 : 1 9.1
ALL ANXIETY 0.7 : 1 9.7
Demographic Factors
AGE – Any (onset around ages 5 to 7)
SEX – Both boys and girls, with age > girls
ETHNICITY/RACE – Any
SES – Any
MARITAL – Any
FAMILY SIZE – Average
PARENTS – Higher in anxiety
Anxiety problems are highly prevalent,
but…
least likely to be detected and referred
Why the low detection and referral rates?
The Internalizing versus Externalizing distinction (the kids who cause the ‘trouble’ get our attention).
Assumption that most childhood anxiety is a transient or temporary, fleeting event.
Transient episodes of anxiety
Are expected and cause relatively little interference in
functioning for the average child or adolescent
Are associated with new or unexpected events (e.g.,
thunder; first day of school)
Can be handled with minimal reassurance or
encouragement
But anxiety disorders in children do not necessarily
remit over time.
Anxiety disorders are also associated
with substantial impairment
Family
Friends
School
Personal Distress
Assessing for impairment…
FISH
Frequency? Every day? once a week? Once a month?
Intensity or Severity?
How long has this been going on? A week? A month? Duration?
Get a rating!
Rates of Diagnosis and Impairment
(N=1,015; ages 9, 11, 13)
Diagnosis/ Diagnosis/ Impaired/
Impaired Not Impaired Not Diagnosed
13.7 % 14 % 20 %
from Angold et al. (1999)
Gateway to other Psychopathologic
Conditions: Developmental Patterns in
Onset
Specific phobia
Separation anxiety disorder
Social phobia
Generalized anxiety disorder
Panic disorder
Depressive disorder
Substance use disorder
Anxiety disorders also are associated with suicidal ideation (Carter, Silverman et al., 2008)
Summary reasons for treating
anxiety disorders in youth
Quiet distress and significant impairment
Do not remit with time
“Gateway” to other disorders including anxiety disorders, dysthymia/depression, and substance use/abuse problems
Successful implementation of
evidence based anxiety treatment
depends on careful conceptualization and
understanding of child’s anxiety problems
DIAGNOSIS & ASSESSMENT OF ANXIETY DISORDERS
DSM-IV Anxiety Disorders
Other disorders of Infancy, Childhood, or Adolescence ◦ Separation Anxiety Disorder
Anxiety Disorders ◦ Specific Phobia
◦ Social Phobia (Social Anxiety Disorder)
◦ Obsessive-Compulsive Disorder
◦ Posttraumatic Stress Disorder
◦ Generalized Anxiety Disorder
◦ Panic Disorder with Agoraphobia
◦ Panic Disorder without Agoraphobia
◦ Agoraphobia without History of Panic Disorder
Sue
Sue, a 4th grader, has stopped attending school. She went the first couple of days with a huge fuss in morning, which continued for a few hours in the classroom. Parents were told that Sue can’t stay in school if this is how she is going to behave. Now things have gotten worse and now she refuses to even get out of bed in the morning. She vomits at night and reports having terrible stomach aches in the morning. She is afraid to sleep alone in her bedroom at night; she has been sleeping in her parents’ bed for over two years.
Separation Anxiety Disorder
Fear of separation from major attachment figures (possible harm)
Avoidance of being left alone
Excessive worry about separation
Physical symptoms on separation
Common fears
◦ Going to school
◦ Being left with sitter
◦ Sleeping away from home
Kevin
Kevin, just transitioned from elementary school to middle school. He is beginning to show increases in absenteeism. When carefully questioned, he revealed that he ‘can’t handle’ the idea that kids are probably laughing at him behind his back. He says ‘he hates having to walk through the hallways between classes, knowing that other people are looking at him.’ He worries constantly what the other kids are thinking about him and he is worried that he might say something or do something ‘dumb’.
Social Phobia
Fear of doing something embarrassing
Avoidance of situations involving potential evaluation
Worry about what others think
Self consciousness
Limited friends
Common fears: ◦ Meeting new people
◦ Speaking in groups (class)
◦ Speaking to authority (teachers)
◦ Standing out
Antonio
Antonio, a 3rd grader, is worried about the FCATs and other tests. On Fridays, test days, the teacher notices that he looks upset and almost as though he might break down and cry. He reports a fear of not being able to move on to 4th grade if he does poorly on the FCAT. He constantly asks his mother and teacher for reassurance that he won’t be retained. No matter what Antonio is told, he still worries. Antonio performs satisfactorily (grade level) in math and reading. He is often absent due to frequent headaches, especially on Fridays.
Generalized Anxiety Disorder
Excessive worry about everyday life issues
Excessive reassurance seeking
Stomach aches, headaches, etc.
Irritability, poor concentration
Common fears:
◦ novelty
◦ Making mistakes
◦ Performance (school sports)
◦ Negative news
Social Phobia vs. GAD
Social Phobia
◦ Worry is focused on performance and social/evaluative situations
◦ The anxiety dissipates upon avoidance or escape of the situation
◦ Difficulty making or keeping friends
◦ Focus is on what other people think
GAD
◦ Worry in areas other than performance or interpersonal
◦ The worry does not stop, even with active avoidance or escape
◦ Friendships are not typically problematic
◦ Focus is usually on a self-imposed, unrealistic standard
Social Phobia vs. SAD
Avoiding social situations because child
does not want to be separated by parent
(SAD) versus child stays away because of
excessive fear of social evaluation (Social
Phobia).
Other common anxiety related
problems
Selective Mutism
School Refusal Behavior
Test Anxiety
Selective Mutism
Consistent failure to speak in specific social situations,
such as school, despite speaking in other situations
Interferes with educational functioning or with social
communication
Symptoms must last at least one month
Mutism not due to lack of knowledge or comfort with
spoken language
Mutism not due to communication disorder, pervasive
developmental delays, or psychosis
Additional Features (subtypes?)
Excessively shy/timid/sensitive/inhibited
Fear of social embarrassment
Social isolation and withdrawal
Clingy/reticent
Compulsive traits/anxious
Negativism/depression
Temper tantrums
Controlling/oppositional behaviors
Traumatized
Is selective mutism a more severe form
of social phobia?
% with SP Diagnosis
Kristensen (2000) 68%
Manassis et al. (2007) 62%
Arie et al. (2006) 44%
Black & Uhde (1995) 97%
Vecchio & Kearney (2005) 100%
School Refusal Behavior
Consists of youth who are completely or partially
absent from school
OR
who show morning misbehaviors to avoid school
OR
attend school under significant distress
Prevalence
average - 8.2% of population
Equally seen in boys and girls
Most common age of presentation – 10 to 13 years
More common among minority populations
School Refusal Behavior (heterogeneous problem)
Wants/needs to be with mom? (Separation Anxiety Disorder, 60%)
Can’t escape if have a panic attack? (Panic Disorder with Agoraphobia, 60%)
Excessive and uncontrollable worry about things (Generalized Anxiety Disorder, 30%)
Social evaluation of kids, teachers (Social Anxiety Disorder, 20%)
Irrational fear about something specific (e.g., loud sound of school bell; Must pass a large dog on way to school) (Specific Phobia, 20%)
Test Anxiety
(heterogeneous problem)
Prevalence - 10 to 41% in school age children
Girls report significantly higher test anxiety than boys
African Americans report significantly higher test anxiety than European Americans
Test Anxiety
“I need to be perfect. I won’t get into college.” (Generalized Anxiety Disorder)
“Others will think I am dumb. My teacher/mom will be disappointed in me.” (Social Anxiety Disorder)
“Taking tests makes me scared (and only tests).” (Specific Phobia)
“I may get those panic attacks during the test.” (Panic Disorder)
Does test anxiety affect high stakes
test scores?
Yes: in a sample of African American
elementary school children, children who
reported high levels of physical symptoms of
anxiety and social anxiety symptoms also
reported high levels of test anxiety. These
children, in turn, received low achievement
levels on the FCAT reading
(Carter, Silverman, & Jaccard, 2011)
Guide for Diagnosing
Anxiety Disorders Interview Schedule for
Children
◦ Child and Parent Versions
◦ Reliability data
◦ Interference ratings for primary,
secondary, etc.
Separation Anxiety Disorder
Social Phobia
Social Phobia
Screening Measures
Multidimensional Anxiety Scale for
Children (March et al., 1997)
Screen for Child Anxiety Related
Emotional Disorders (Birmaher et
al.,1997)
Spence Children’s Anxiety Scale (Spence,
1998)
Spence Children’s Anxiety Scale
www.scaswebsite.com 38-item questionnaire Child version for ages 8-15 Parent version for ages 6-18 Responses are scored: ◦ Never = 0 ◦ Sometimes = 1 ◦ Often = 2 ◦ Always =3
Changing Self Talk Gather evidence by asking yourself the following questions…
1. Do I know for sure this is going to happen?
2. What else might happen, other than what I first thought?
3. Has it happened before?
4. Has this happened to anyone I know?
5. How many times has it happened before?
6. After collecting the evidence, what are the odds of ___________?
7. So, what is a coping thought I can have in this situation?
Additional questions to consider:
1. Is worrying about this helping?
2. What am I missing out on because I am worrying?
Optimizing gains
Assessment and targeting the core fear(s)
Directed discovery
Involvement
Cooperation/collaboration
Relapse prevention (dealing with frustration)
Working for generalization
Arranging termination
Individualizing the program
Therapist flexibility (within fidelity)
Interfering with gains
Teachy-preachy style
Forcing youth to talk about feelings (Creed & Kendall, JCCP, 2005)
Excessive focus on tasks
Mechanical self-talk
“Wimpy” exposures
Way too scary exposures
Child depression?
Conflictual relations?
For more information, please go to the main website and browse for more videos on this topic or check out our additional resources.
Additional Resources Online resources: 1. Society of Clinical Child and Adolescent Psychology website: http://effectivechildtherapy.com/sccap/ 2. Spence Children’s Anxiety Scale: www.scaswebsite.com
Books: 1. Silverman, W.K. & Field, A. P. (2011). Anxiety Disorders in Children and Adolescents (2nd Ed.)New York, NY: Cambridge University Press. 2. Silverman, W.K., & Albano, A.M. (1996). The Anxiety Disorders Interview Schedule for Children for DSM-IV: (Child and Parent Versions). San Antonio, TX: Psychological Corporation.
Peer-reviewed Journal Articles: 1. Carter, R., Silverman, W.K., & Jaccard, J. (2011). Sex variations in youth anxiety symptoms: Effects of pubertal development and gender role orientation. Journal of Clinical Child & Adolescent Psychology, 730-741. 2. Creed, T. A., & Kendall, P.C. (2005). Therapist alliance-building behavioral within a cognitive-behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73(3), 498-505. 3. Ollendick, T., & King, N.J. (1991). Origins of childhood fears: An evaluation of Rachman’s theory of fear acquisition. Behaviour Research and Therapy. 29(2), 117-123. 4. Pine, D.S., Helfinstein, S. M., Bar-Haim, Y., Nelson, E., & Fox, N. A. (2008). Challenges in developing novel treatments for childhood disorders: Lessons from research anxiety. Neuropsychopharmacology, 34,213-228. 5. 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.