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CONTENTS
 Beyond Behavioral Inhibition: Etiological Factors in Childhood AnxietyKatharina Manassis, Jennifer L. Hudson, Alicia Webb, and Anne Marie Albano
REGULAR ARTICLES
COGNITIVE BEHAVIORAL CASE CONFERENCE
Video Review Monkey See Productions, Living With Schizophrenia ABSTRACTS
The special series brings together a number of progressive topics in the field of child and adolescent anxiety. The articles include reviews of current literature, descriptions of state-of-the-art research, and practical clinical applications relevant to the assessment and treatment of anxious youth, but vary in their emphasis on each of these elements. Three main themes emerge in the series relevant to the field of child and adolescent anxiety disorders: etiology, assessment, and treatment. Theoretical models of childhood anxiety have emphasized temperamental vulnerability, principally behavioral inhibition, and its interaction with various environmental factors promoting anxiety (for example, overprotective parenting, insecure attachment, life stress). Although clearly establishing the importance of both nature and nurture in anxious psychopathology, these models have not adequately explained the diversity of anxiety disorders presenting in childhood, the fact that some children’s diagnoses change over time, and the progression (in some children) from highly cormorbid presentations in middle childhood to one predominant disorder in adolescence. This paper presents additional factors that may be helpful to consider when trying to understand these findings and describes applications to promote healthy adjustment in anxious youngsters. Such factors include specific risks for certain disorders, developmental changes and cultural factors affecting the intensity and expression of anxiety, and the emergence of various more or less adaptive coping styles. Social anxiety affects children across the developmental spectrum. Early-onset social phobia may be particularly impairing because of its disruptive effects on social and academic functioning during a child’s formative years and because of the elevated risks of childhood adversity in anxious individuals. Unfortunately, little attention has been paid to the early identification and assessment of social anxiety in young children. The ability to recognize and monitor or remediate social anxiety early in development would be of great advantage in reversing this potentially debilitating course. This article reviews various methods available to assess social anxiety and associated conditions. Particular emphasis is placed on the description and assessment of behavioral inhibition in infants and very young children as an early marker or precursor to the development of social anxiety. For school-aged children and adolescents, a greater range of assessment options is available including behavioral observation, clinician ratings, child self-report questionnaires, and parent and peer reports. In an effort to advance our understanding of the developmental psychopathology of social anxiety, further research is necessary to determine the equivalency of various assessment strategies across developmental periods. Accumulating evidence indicates that family/parenting behaviors are associated with the etiology of anxiety disorders in children. This article critically reviews what is known about how family/parenting behaviors have been measured in this literature and presents findings from studies examining the relation between family/parenting constructs and anxiety disorders in children. We review of the role of family involvement in the treatment of anxiety disorders in children and conclude with avenues of future research.
A strong therapeutic alliance is intuitively important in a cognitive-behavioral treatment of anxious youth where the child must confront feared stimuli in numerous exposure tasks. Research examining alliance-outcome relationships and the specific role of the alliance is currently limited. Is the alliance supportive in nature, does it enhance client motivation, or is it an active mediator through which change occurs? Technology-based treatment aids and modalities (e.g., interactive CDs, virtual reality exposure, and single-session treatment) offer the potential benefit of promoting active child engagement, an essential goal of CBT, but they also challenge traditional notions of the therapeutic relationship. Conceptual definitions and methodological considerations for assessing the alliance in child anxiety treatment are discussed. A review of technology, outcome, and its effect on process follows, concluding with a recommendation that further alliance research is necessary and that advanced technologies provide an opportunity to understand the treatment process further.
Exposure interventions, both imaginal and in vivo, are an integral part of cognitive behavioral treatments for anxiety disorders and have been found to be efficacious when used to treat various fears and phobias. Although most of the literature has focused on the use of exposure with adults, there is increasing interest in the use of these techniques with anxious children and adolescents. The premise underlying exposure’s efficacy is that although it is initially uncomfortable, anxiety will eventually diminish and erroneous cognitions will be disconfirmed when one is exposed repeatedly to a feared stimulus in the absence of the feared negative consequence. In this paper the use of exposure techniques with children and adolescents will be discussed, focusing particularly on increasing the developmental sensitivity of these techniques to maximize their effects for younger patients. Various exposure techniques in younger patients will be described, core principles of exposure treatment for anxious children will be delineated, and application for specific pediatric anxiety disorders will be discussed.
Select research and practice issues that merit further attention are described. Specifically, we argue that the pathways for profitable research include studies of normative development, assessment and diagnostic considerations, the role of parents, and the ways to optimize the conduct and evaluation of treatment. At present, the field is too uninformed about the development of emotions (e.g., anxiety) and emotion regulation, about adolescence and particular vulnerabilities associated with adolescence, and about the longitudinal course of anxiety in youth. Improved measures, as well as a better understanding of and recommended solutions for parent child disagreements are needed. How do parents maintain distressing anxiety in their children, and what is the optimal role for parents in the treatment of anxious children? The role of parents may vary across development, and there may be differential advantages and disadvantages for younger children, middle-aged children, and adolescents, and for the different types of anxiety disorders. Although cognitive-behavioral therapy is a probably efficacious treatment, and well on its way to becoming a well-established treatment, much more information is needed about the potential role of medications and the merits of enhancing the therapeutic alliance. Our discussion focuses on mapping the further evolution and maturation of the field of child anxiety.
Asperger’s Syndrome (AS) is a developmental disorder characterized by social impairment, highly circumscribed interests, repetitive behaviors, and motor clumsiness. The social impairment features of AS are similar to characteristics of social anxiety disorder (SAD). However, little is known about the comorbidity of these disorders or the treatment of social anxiety in the context of AS. The present single-subject report examines the use of cognitive-behavior therapy (CBT) in treating SAD in an adult with comorbid AS. The results suggest that a 14-week course of CBT was successful in reducing symptoms of anxiety and comorbid depression. In addition, improvements in social skills were observed (e.g., appropriate eye contact, conversational skills). Limitations and future directions for research and treatment are discussed.
Cognitive behavioral treatment (CBT) protocols for panic disorder (PD) typically include some form of interoceptive exposure (IE)—repeated exposure to internal sensations. Despite the widespread clinical use of IE, there is a notable absence of empirical reports about the nature of interoceptive assessments and IE. The present study was designed to describe the type, frequency, and typical anxiety extinction for a variety of interoceptive exercises typically used to treat panic disorder. Interoceptive assessment and IE data were compiled for patients with PD completing a CBT protocol. Data suggest that interoceptive assessment typically provokes fairly specific symptoms that often result in anxiety and even panic. On average, patients completed approximately 25 IE sessions during the course of treatment. Despite the use of a wide variety of interoceptive exercises, 4 exercises (hyperventilation, breathing through a narrow straw, breath holding, and spinning) accounted for the majority of IE sessions, and the majority of IE sessions led to within-session anxiety reduction.
In this article, we describe a pilot study that investigated the effectiveness of group cognitive behavioral therapy (CBT) for auditory hallucinations. Eleven inpatients with either chronic schizophrenia or schizoaffective disorder participated in 2 CBT groups of differing treatment duration (i.e., 7 versus 20 sessions). The results showed that participation in both groups was associated with significant positive changes in the participants’ beliefs about their voices and with a trend for reduced negative reactions to the voices. These changes were not a function of premorbid cognitive functioning. Finally, duration of treatment did not affect participants’ beliefs or distress associated with the voices. Implications for future clinical research in this area are discussed.
For the treatment of disruptive behavior disorders, parent training and child social skills training have established efficacy in research settings. But in community settings, these approaches are not often systematically implemented. In a hospital-affiliated psychology practice located in a rural community, parent and child group programs were set up to be the standard initial treatment for these disorders for children ages 5 to 12 years. Using the Eyberg Checklist for pre and post measures, 51 patients who completed treatment showed an average treatment effectiveness of 1.00 standard deviation, which is comparable to outcome data from an earlier study in which the same program had been instituted in a suburban setting (Tynan, Schuman, & Lampert, 1999). COGNITIVE BEHAVIORAL CASE CONFERENCE
Health anxiety can present a challenge for clinicians, both from the perspective of assigning a DSM-IV diagnosis and in developing an appropriate treatment plan. The case of Mrs. A. illustrates some of the complexities that arise in the diagnosis and treatment of health anxiety. Mrs. A. is a 60-year-old retired teacher who presented to a specialized anxiety clinic with a wide range of health anxiety symptoms. The details of Mrs. A.’s case are presented along with information obtained during her assessment. Issues related to conceptualization and potential obstacles to treatment are highlighted. This case is discussed by a number of experts in the field of health anxiety who provide different cognitive-behavioral perspectives on conceptualization and treatment planning. Response Paper
Patients with health anxiety often present challenges to assessment and treatment planning. The case of Mrs. A. provides examples of several clinical issues common to these patients. Her symptoms cross several DSM diagnostic categories, with a primary presentation of hypochondriasis and secondary presentation of illness phobia. In this article we detail our approach to case conceptualization, outline assessment strategies, and consider treatment options and strategies. Specific attention is given to the challenge of having Mrs. A. willingly explore the possibility that her bodily signs and sensations are better accounted for by explanations other than physical disease. RESPONSE PAPER
Mrs. A. presents with a textbook case of hypochondriasis. An additional diagnosis of OCD does not enhance our understanding or treatment of her problems, and is not indicated according to DSM-IV. Cognitive-behavior therapy (CBT) is effective in treating hypochondriasis, although it is necessary to devise a case formulation for each patient to determine which interventions to use and how to best implement them. A detailed cognitive and behavioral assessment is essential to successful treatment. In this commentary, I describe the important assessment areas that need to be covered to better understand Mrs. A.’s problems and the obstacles to assessment that might be encountered. A tentative case formulation is presented, based on the available information, and a tentative CBT protocol is derived. Likely obstacles to successful treatment, such as Mrs. A.’s poor insight into her disorder, need to be more thoroughly assessed in order to devise strategies for circumventing these difficulties. |