Comprehensive Evidence Based Interventions for Children and Adolescents

Candice A. Alfano, Deborah C. Beidel, Candice A. Alfano, Deborah C. Beidel

• Publisher: Wiley
• Year: 2014
• Print ISBN: 9781118487563
• eBook ISBN: 9781118864821
• Edition: 1
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

A complete guide to evidence based interventions for children and adolescents

The past decade has witnessed the development of numerous interventions proved to be highly effective; several treatments are now considered to be "well established" or "probably efficacious" interventions for children. Given the range of providers working with children—clinical psychologists, child psychiatrists, clinical social workers, school psychologists, and marriage and family therapists—this book is designed to provide all professionals the information they now need about the use of these evidence-based interventions (EBIs), as well as the evaluation criteria used to determine their efficacy in in meeting the mental health needs of children.

Alfano and Beidel have assembled a team of experts to write the disorder chapters. Each chapter begins with an overview of the disorder then delves into evidence-based approaches to treatment, the impact of parental involvement, case-by-case modifications, progress measurement, and clinical examples. In overview chapters the editors cover:

• The role of development in treatment planning and implementation
• Dissemination of EBIs into school and community settings
• The use of controversial therapies with children
• Emerging methods of service delivery and access improvement

Comprehensive Evidence Based Interventions for Children and Adolescents provides clinicians, researchers, and students alike with the theoretical, conceptual, and practical skills to provide children and adolescents with the best care possible.

SECTION II
Disorder-Focused Interventions

Chapter 7
Anxiety Disorders in Children^a

Laura D. Seligman, Erin F. Swedish, and Thomas H. Ollendick

BRIEF OVERVIEW OF DISORDERS

Anxiety disorders in children describe a broad spectrum of syndromes (Grills-Taquechel & Ollendick, 2013). According to the Diagnostic and Statistical Manual, 4th ed. (DSM-IV) (American Psychiatric Association [APA], 1994), children with significant and interfering anxiety can be diagnosed with one or more of eight anxiety disorders (APA, 1994; World Health Organization, 1992):

1. Panic disorder with agoraphobia
2. Panic disorder without agoraphobia
3. Agoraphobia without history of panic
4. Specific phobia
5. Social phobia
6. Obsessive-compulsive disorder
7. Posttraumatic stress disorder
8. Generalized anxiety disorder

Additionally, the DSM-IV and the International Classification of Diseases, 10th revised ed. (ICD-10) specify one anxiety diagnosis specific to childhood: separation anxiety disorder (SAD). However, in the most recent version of the DSM, the DSM-5 (APA, 2013), the age-of-onset requirement for SAD has been dropped; thus, SAD is listed among the anxiety disorders. In addition, DSM-5 moves obsessive-compulsive disorder to a new chapter for obsessive-compulsive and related disorders and removes posttraumatic stress disorder (PTSD) from anxiety disorders and places it in a section titled “Trauma and Stressor-Related Disorders.”

As is evident from this discussion, what is and what is not considered an anxiety disorder by diagnostic classification systems is especially fluid right now. Generally speaking, a broad range of topics can be subsumed under the heading of anxiety disorders in childhood. Due to space constraints, however, we have chosen to limit the more specific aspects of our discussion to the examination of SAD, generalized anxiety disorder (GAD), social anxiety disorder (SOC), and specific phobias (SPs); several papers provide excellent resources for the reader interested in review of the literature on other anxiety disorders in youth (Cary & McMillen, 2012; Franklin, Harrison, & Benavides, 2012; Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2012; Ollendick, Mattis, & King, 1994).

Separation Anxiety Disorder

Developmentally inappropriate or excessive anxiety or fear upon separation from attachment figures (usually a parent or primary caregiver) or from home for a duration of at least 4 weeks is the core feature of SAD as defined by both the DSM-5 and the ICD-10 diagnostic criteria (APA, 2013; WHO, 1992). Children with SAD may experience a variety of behavioral (e.g., clinging to attachment figure, crying) and somatic symptoms (e.g., muscle aches, headaches) upon separation from or in anticipation of separation from the attachment figure. Children with SAD experience intrusive worries that something might happen to the attachment figure or to the child him-/herself. Furthermore, a child with SAD may be reluctant to sleep alone or to sleep away from home. School refusal is associated frequently with SAD and can be one of the most debilitating symptoms for both the child and the family. Moreover, comorbidity of SAD with other anxiety disorders and with depression is common (Black, 1995; Last, Hersen, & Kazdin, 1987).

Of note, there is a good deal of variation across cultures regarding expectations for separation; thus, the severity of clinical symptoms that warrant a diagnosis of SAD may vary widely depending on the child’s contextual environment. Thus, it is important to assess for and take into account cultural norms regarding separation when considering a diagnosis of SAD.

Generalized Anxiety Disorder

The core feature of GAD is excessive worrying related to a number of events or activities (e.g., world events) that lasts for a period of six months or more (APA, 2013; WHO, 1992). This worry is difficult to control or stop; children with GAD may experience difficulty concentrating on schoolwork or social interactions because of their focus on their worries. Additionally, the worry is accompanied by somatic complaints and distress. As with SAD, children with GAD have a high rate of concurrent mental health disorders (Costello, Egger, & Angold, 2005).

Social Anxiety Disorder (Social Phobia)

Social anxiety disorder or social phobia is characterized by an excessive fear of negative evaluation by others. Often this extreme fear of judgment and evaluation is in situations with unfamiliar people or situations that could possibly result in scrutiny. The anxiety must be present in a variety of interactions (e.g., with peers, not just in interactions with adults) for a diagnosis of SOC to be made. Typically, children with social anxiety avoid social interactions to the extent that normal daily functioning can be greatly impaired (Stein & Gorman, 2001). The onset of SOC generally occurs during adolescence (approximately 13 years of age, on average); however, SOC can become evident during early childhood (Beidel, Turner, & Morris, 1999). As with other anxiety disorders, children with SOC often present with comorbid disorders; moreover, SOC in youth is associated with increased risk of substance abuse disorders later in life (Buckner et al., 2008).

Specific/Simple Phobia

Specific (simple) phobia is defined by excessive and marked fear in response to encountering or anticipating an object or situation (e.g., heights, small places, animals) (APA, 1994). The fear causes distress and interference in the child’s routine, and the feared stimulus is generally avoided. Although adults often realize that their fears are excessive and unreasonable, this may not always be the case for children. It is estimated that SPs occur in about 8% of children (Kim et al., 2010). Again, children with SPs often present with comorbid disorders (Kim et al., 2010).

EVIDENCE-BASED APPROACHES

Over the past few decades, research has identified various evidence-based approaches for children with anxiety disorders. More specifically, research suggests that some treatments work better than others for children who experience anxiety and that cognitive behavioral therapy (CBT) has a relatively strong evidence base (Seligman & Ollendick, 2011). Although there are variations in the specific approaches for different anxiety disorders, in general CBT for child anxiety focuses on the cognitive and behavioral processes hypothesized to lead to and maintain anxiety. More specifically, the core components of CBT for anxious youth include psychoeducation, emotion education, problem solving, cognitive restructuring, exposure, and relapse prevention. Treatment programs typically last from 12 to 18 sessions, although some treatments have been shown to be efficacious with as few as 8 to 10 sessions (Rapee, 2000).

COMMON COMPONENTS OF EVIDENCE-BASED TREATMENTS FOR CHILDREN WITH ANXIETY DISORDERS

Although many evidence-based treatment programs and packages have been identified, these treatments are based on common core components. These components are discussed next.

Psychoeducation and Emotion Education

Psychoeducation efforts are aimed at helping the child and his/her family understand the treatment rationale and lay the foundation for the skills that are the focus of later sessions. Children and their families are given basic information regarding anxiety and are introduced to the CBT model and specifically the interaction among thoughts, feelings, and behavior. Maintaining factors of anxiety are discussed, with a particular focus on avoidance and accommodation. This may be the first time that the family begins to consider that accommodation of anxious behavior and/or avoidance of anxiety-provoking stimuli are not necessary reactions to anxiety. Therapists focus on helping families understand that the experience of anxiety is not, in and of itself, dangerous and that anxiety does not spiral out of control and continue indefinitely, as many people believe.

Psychoeducation also typically involves helping children to recognize and distinguish feelings and increase their awareness of their emotions. Emotion education can help children to identify the specific situations that lead to anxiety. This process can set the stage for later efforts at using coping strategies and monitoring anxious cognitions.

Problem Solving

Problem-solving methods are taught and practiced in order to help children identify new methods for addressing anxiety-provoking situations. Children are taught to use a step-by-step process that includes finding multiple solutions to a problem, examining the costs and benefits of each, and implementing the preferred solution. Given that research suggests that children with anxiety disorders prefer avoidant ways to cope with anxiety and that this behavior may be encouraged by parents (Dadds, Marrett, & Rapee, 1996), problem solving can serve the important function of allowing children to recognize that other approach-oriented options are available and to examine the pros and cons of avoidant versus approach behaviors.

Cognitive Restructuring

Cognitive restructuring helps children identify and replace maladaptive thoughts and beliefs with more adaptive thoughts and beliefs. Learning to think more realistically is an important strategy for helping children overcome anxiety. In order for children to change their thoughts, it is important for them to first understand the relationship among thoughts, feelings, and behaviors. That is, it is important for children to understand that their feelings and emotions are not directly caused by the events and situations that occur but instead by the way events are thought about and interpreted. Such an approach may also allow anxious children to begin to feel more control over their emotions.

Cognitive restructuring efforts often focus on two common errors made by children with anxiety disorders: overestimation of the probability of threat or negative outcomes and overestimation of the negative consequences of an event, should it occur. For example, a little boy who experiences social anxiety when starting a conversation with peers may be taught to examine and modify his automatic thought that other children will laugh at him if he says something wrong when joining a group, or he may be encouraged to modify his beliefs about how bad it would be if the other children did indeed laugh at him.

Given that most anxious children think in these unrealistic ways, it is important for children to recognize their thought patterns and identify their dysfunctional beliefs so they might begin to develop more adaptive ways of thinking. However, the concept of cognitive restructuring and the process of actually changing thoughts is difficult, even for adults. Therefore, when working with children, cognitive restructuring often is introduced as a game in which children are encouraged to become detectives to first find anxiety-provoking thoughts and then to find various clues to determine whether their anxious thought is accurate.

Exposure

Most anxious children have developed ways to avoid the situations that are frightening for them. Therefore, they never allow themselves the opportunity to learn that neither the feared situation nor the experience of anxiety is dangerous. As such, a central component of almost all evidence-based approaches to the treatment of anxiety disorders in children is some form of exposure and response prevention. Often chi...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Dedication
• Preface
• About the Editors
• Contributors
• Section I: Treatment Considerations and Contextual Issues
• Section II: Disorder-Focused Interventions
• Section III: Other Interventions for Children
• Author Index
• Subject Index
• End User License Agreement