Improving access to treatment for anxiety disorders in children through low intensity interventions

Transcription

1 School of Psychology and Clinical Language Sciences Improving access to treatment for anxiety disorders in children through low intensity interventions Cathy Creswell 29 January 2015 University of Reading

2 Childhood onset Lifetime prevalence of anxiety disorders Annual UK cost 19 billion 290,000 UK children affected at any time

3 The good news CBT (typically sessions) is better than nothing (e.g. James et al ) % free primary diagnosis CBT Waitlist control Active control CBT is a bit better than something (Ginsburg et al., 2002; Hudson et al., 2009; Kendall et al., 2008)

4 The bad news Number of children/young people (<20 years) per CAMHS specialist Switzerland Finland France UK Pedrini et al., 2012; Levay et al., 2004; WHO,

5 The bad news CBT is not easily accessed Only ¼ of children with mental health problems have seen a mental health professional in the last year (in Layard, 2008) >2/3 CAMHS professionals identify training needs in core CBT skills (Stallard et al, 2007)

6 A stepped care approach (Bower & Gilbody, 2005) More intensive treatments reserved for those who don t benefit Least restrictive from step 1 treatment (cost/ inconvenience) that is likely to provide significant health gain 6

7 Improving access for young people through self-management approaches? Evidence that manual for parents can be effective in reducing child symptoms of Depression (Ackerson et al, 1998) Oppositional behaviour (Long et al, 1993) Chronic headaches (Griffiths & Martin, 1996) Enuresis (vanlondon et al, 1993) Post-operative pain (Chambers et al, 1997) Modest impact of unguided self-help for childhood anxiety disorders (Rapee et al, 2006) But very positive results with telephone support for rural Australian populations (Lyneham & Rapee, 2006)

8 CBT: a simple anxiety example Something bad is going to happen Don t find out that situation was OK. Don t develop skills to cope Fear / physiological response Escape or avoidance of the situation

9 Don t find out that situation was OK. Don t develop skills to cope Something bad is going to happen Fear Parents of anxious children are more likely than parents of nonanxious children to - expect child responses to be characterised by threat interpretation, negative emotions, low control - view themselves as having reduced control over child responses Escape or avoidance of the situation e.g. Barrett et al., 1996; Creswell et al., 2006; Kortlander et al., 1997;Micco & Ehrenreich, 2008; Wheatcroft & Creswell, 2007 Expectation of low coping/ high distress

10 Manipulating parental expectations influences parental control vs autonomy promotion Creswell, Brewin & O Connor (2008), BCP

11 Something bad is going to happen Don t find out that situation was OK. Don t develop skills to cope Fear Escape or avoidance of the situation Reduced encouragement / take control Expectation of low coping/ high distress

12 Effect of manipulating parental behaviour on observed child anxiety Thirlwall & Creswell, 2010

13 Don t find out that situation was OK. Don t develop skills to cope Something bad is going to happen Fear Excessive regulation of behaviour and discouragement of independence leads to child belief that world is dangerous reduced sense of competence and mastery reinforcement of avoidance of challenge E.g. Hudson & Rapee, 2004, Chorpita & Barlow, 1998 Escape or avoidance of the situation Parental autonomy-granting reliably associated with child anxiety (ES= 0.42) McLeod et al, 2007 Reduced encouragement / take control Expectation of low coping/ high distress

14 Situation: In the morning before school She is going to make herself ill There is nothing I can do to help her once she is at school Gives phone so can call home if a problem Feels anxious and tense

15 Implications for treatment delivery Treatment for childhood anxiety may be efficiently delivered via parents as parents are in a position to: Learn and teach child CBT skills and apply within the child s day to day life By giving parent alternative ways of responding to child difficulties, treatment can modify reinforcement cycles within the family 15

16 Delivering CBT for child anxiety via parents Cartwright-Hatton et al (2010) <10 years Condition Dose % free primary diagnosis Wait list 18% Parents only 10 sessions x 2 hours 65.6% Waters et al (2009) 4-9 years Condition Dose % free primary diagnosis Parents only (n=25) Parents + children (n=24) 10 weekly sessions x 1 hours 2 x 10 weekly sessions x 1hours 55.3% 54.8%

17 A brief parent only intervention Guided CBT Self-Help 8 sessions with parent(s) 4 face to face (60 mins) 4 telephone reviews (15-20 mins) Total therapist contact time = 5hrs-5hr20 mins Therapist encourages parent(s) to work through manual rehearses key skills with parent(s) Helps parent(s) problem solve challenges that arise

18 Treatment content Introduction to anxiety Possible causes, maintenance cycles, implication for treatment Helping children to identify and test out thoughts Graded exposure with positive reinforcement Parental responses to anxiety/ brave behaviours Problem solving 18

19 The Overcoming programme: Guided CBT self-help treatment of child anxiety disorders To establish the efficacy of guided CBT self-help for childhood anxiety disorders (in the absence of parental anxiety disorder) To examine Full (5 hours) and Brief (2.5 hours) versions of the intervention To examine the relation between therapist training and treatment outcomes Thirlwall, Cooper, Karalus, Voysey, Willetts & Creswell (2013; BJPsychiatry) 19

20 The Overcoming programme: Guided self-help treatment of child anxiety disorder Treatment Group 1: GSH (n=62) 4 face to face appointments with parents 4 telephone appointments Over 8 weeks (total 5 hrs) Group 2: Short GSH (n=62) 2 face to face appointments with parents 2 telephone appointments Over 8 weeks (total 2.5 hrs) Group 3: Waitlist control (n=62) Wait list Assessment 12 weeks 12 weeks 12 weeks Follow-up 6 months 6 months If ongoing anxiety randomise to either group 1 or 2

21 Assessed for eligibility n=552 Eligible n= 219 Randomised n= 194 Full CBT n= 64 Brief CBT n= 61 Wait list n= 69 Assessment (12 weeks) n= 50 Assessment (12 weeks) n= 46 Assessment (12 weeks) n= 63 Assessment (6 months) n= 49 Assessment (6 months) n= 38 Thirlwall, Cooper, Karalus, Voysey, Willetts & Creswell, British Journal of Psychiatry (2013). 21

22 Diagnostic status of the children (%) Present Primary Generalised Anxiety Disorder (GAD) Separation Anxiety Disorder Social Anxiety Disorder Specific phobia

23 Treatment outcomes Free of primary diagnosis Free of all anxiety diagnoses Full Brief Waitlist Full Brief Waitlist Full CBT > WL (RR: 1.77, 95% CI , p=.02) Brief CBT-WL (RR: 1.50, 95% CI , p=.15) Full CBT > WL (RR: 3.14, 95% CI , p=.005) Brief CBT-WL (RR: 1.48, 95% CI , p=.26) 23

24 Therapist qualifications and outcomes (free of primary diagnosis) CBT trained CBT novice 10 0 Full Brief Full CBT: RR =1.0, 95% CI= Brief CBT: RR=1.87, 95% CI=

25 Application in Primary Care High level of therapist adherence High level of parental satisfaction High level of PMHW satisfaction >90% clips coded at high level of adherence 82% level of contact just right This programme seemed to have an impact on not only the child but also on the parents positively. It fits in so well with the PCAMH Service and interventions Creswell, Hentges, Parkinson, Sheffield, Willetts, & Cooper (2010) 25

26 Outcome data in Primary CAMHS Clinician s Global Impressions Scale: Improvement 76% much / very much improved Primary diagnosis 61% diagnosis free All anxiety diagnoses 44% diagnosis free Creswell, Hentges, Parkinson, Sheffield, Willetts & Cooper, 2010

27 Ongoing evaluation Guided CBT Self-Help n=68 PCAMHS Alternative Treatment n=68 5 hours therapist guidance 4 x face to face 4 x telephone reviews 5 hours Solution Focussed Brief Therapy 12 week assessment 12 week assessment Follow-up assessment 6 months post-treatment Follow-up assessment 6 months post-treatment Full economic analysis

28 Summary Guided CBT self help is effective and can be delivered by novice therapists Working via parents provides an efficient and effective means to deliver treatment for childhood anxiety disorders Treatment provides parents with Skills and confidence to manage child difficulties Alternative responses to those that may reinforce child anxious cognitions and behaviours 28

29 Predictors of treatment outcome (CGI) Predictor Child age r(40)=.20, p=.22 Child gender Child anxiety symptoms pretreatment (SCAS p; SCAS-c) Maternal stress or depression (DASS) Maternal anxiety (DASS) t(40)=.36, p=.72 r(39) =.14, p=.40 r(33)=.16, p=.38 r(39)=.07, p=.69 r(38)=.07, p=.66 r(38) =.35, p=.03 Creswell, Hentges, Parkinson, Sheffield, Willetts & Cooper,

30 % Children free of anxiety diagnoses

31 % Current anxiety disorder amongst the mothers of anxious and non-anxious children anxious children (n=85) non-anxious children (n=45) Any Anxiety Disorder Specific Phobia Social Phobia GAD Cooper et al (2006) J.Affect Disorders

32 % children free of anxiety diagnosis What needs to change? Cobham et al (1998) Hudson et al (2013)

33 Studies with community populations indicate that high parental anxiety is associated with: Increased threat interpretation re own world Extends to increased threat interpretation re child s world, anticipation of greater child distress, reduced perceived control of child s anxious behaviour Creswell & O Connor, 2006; Lester et al, 2008; Wheatcroft & Creswell, 2007 Child anxiety Parent anxiety Threat oriented interpretations Avoidant behaviour Information processing biases Physiological response Reduced encouragement, increased involvement Parental negative expectation of child response 33 Creswell, Murray, Stacey & Cooper, 2010

34 Studies with community populations indicate that high parental anxiety is associated with: Increased threat interpretation re own world High parental anxiety may have a particularly Extends salient to effect increased on parental threat responses interpretation when re child s children world, themselves anticipation are anxious of greater child distress, reduced perceived control of child s anxious behaviour Creswell & O Connor, 2006; Lester et al, 2008; Wheatcroft & Creswell, 2007 Child anxiety Hirshfeld et al, 1997 Parent anxiety Threat oriented interpretations Avoidant behaviour Information processing biases Physiological response Reduced encouragement, increased involvement Parental negative expectation of child response 34 Creswell, Murray, Stacey & Cooper, 2010

35 Participants Mothers with current anxiety disorder (ANX) Mothers not currently anxious (NONANX) n Child age (mean, sd) Gender (% female) SES (% professional) Ethnicity (% White UK) Spence Child Anxiety Scale- child report (mean, sd) Depression Anxiety Stress Scale: Anxiety (mean, sd) Depression Anxiety Stress Scale: Depression (mean, sd) (19.94) (15.88) 8.41 (7.58)*** 2.36 (2.74)*** (8.80)*** 3.77 (4.53)*** 35

36 Challenge tasks Tangram puzzle Mysterious box Preparing and giving a speech

37 Post-task ratings Maternal anxiety Behaviours Maternal expressed anxiety Maternal anxiety status (F (4,75) = 3.52, p =.01; partial η² =.16), child expressed anxiety (F (4,75) = 7.65, p <.001; partial η² =.29), mat x child anx (F (4,75) = 3.97, p =.006, partial η² =.18); maternal depressed mood(f (4,75) =.83, p =.51; partial η² = Maternal anxiety status (F (6,76) = 2.65, p =.02; partial η² =.17), child expressed anxiety (F (6,76) = 4.12, p =.001; partial η² =.25), child x mat anx (F (6,76) = 2.71, p =.02, partial η² =.18), maternal depressed mood (F (6,76) = 1.64, p =.15; partial η² =.12). 37

38 Maternal behaviours Intrusiveness r(85)=.30** Maternal expectations of control of child response Intrusiveness Maternal anxiety status (F (6,76) = 2.65, p =.02; partial η² =.17), child expressed anxiety (F (6,76) = 4.12, p =.001; partial η² =.25), child x mat anx (F (6,76) = 2.71, p =.02, partial η² =.18), maternal depressed mood (F (6,76) = 1.64, p =.15; partial η² =.12). 38

39 Maternal selfreported anxiety during task Maternal group Quality of relationship Indirect path: Mean=-.19, s.e.=.11, 95% CI= -.45 to

40 Summary Despite no differences in observed child anxiety, anxious mothers Anticipated poorer child performance and less parental control over child response Displayed higher intrusiveness Experienced higher anxiety Effects moderated by extent task provoked child anxiety Anxious mothers do not adapt expectations in line with observed child anxiety and respond with higher perceived control and intrusiveness Anxious mothers experience high levels of anxiety in response to their child s distress and this is associated with more negative interactions 40

41 Are outcomes from parent led treatment improved in context of high parental anxiety by promoting Tolerance of Children s Negative Emotions (TCNE)? Overcoming supplemented with TCNE : Parent/child formulation to identify parental responses that may maintain child anxious responses Coping imagery/ Press Pause Helping parents to manage child negative emotions, e.g. cognitive technique All participating parents (n=60) scored above DASS cut-offs or met criteria for anxiety diagnosis 41

42 Overcoming + TCNE (n=30) vs Overcoming (n=30) CGI: % Much/Very much improved TCNE Overcoming % free of primary diagnosis TCNE Overcoming 42

43 Parental acceptance of child s negative emotions PAAQ pre PAAQ post TCNE Overcoming 43

44 Change in parental affect Trait anxiety (DASS) In task anxiety Parent anxiety pre post Parent anxiety pre post 44

45 Change in parental behaviours Intrusiven ess pre post Anxiety pre post 45

46 Parental satisfaction Book Help from therapist Recommend? TCNE Overcoming 46

47 Summary Although particular cognitive, affective and behavioural responses are heightened among highly anxious parents pre-treatment, many of these reduce in response to treatment Additional measures to target these factors may not be necessary in addition to Overcoming Focus on increasing parental confidence/efficacy through skill sharing Focus on promoting sense of child competence through graded exposure, promoting autonomy Were the extra sessions of benefit? Therapist experience? Who doesn t benefit? 47

48 Where are we now? And where are we going? Brief parent-led CBT is effective for a significant proportion of children with anxiety disorders Fulfils requirements for a first-step approach Brief parentled CBT? Can access be improved further? Why doesn t it work when it doesn t work? What do those families need as a second step? 48

49 49