2/28/2017. A Briefer on the Active Ingredients of CBT for Anxiety Disorders in Youth with Special Consideration of Copresenting.

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1 A Briefer on the Active Ingredients of CBT for Anxiety Disorders in Youth with Special Consideration of Copresenting Concussion K a t h e r i n e D a h l s g a a r d, P h. D., A B P P C l i n i c a l D i r e c t o r A B C : T h e A n x i e t y B e h a v i o r s C l i n i c T h e P i c k y E a t e r s C l i n i c D e p a r t m e n t o f C h i l d & A d o l e s c e n t P s y c h i a t r y & B e h a v i o r a l S c i e n c e s T h e C h i l d r e n s H o s p i t a l o f P h i l a d e l p h i a Conflicts of Interest/Disclosures The content represents the presenter s personal opinions and does not necessarily represents the position of the presenter s employer or previous training sites. Paid contributer to: Philadelphia Inquirer Anxiety.org Objectives Review evidence-based treatment for pediatric anxiety disorders Discuss mechanisms of maintenance & active ingredients of CBT Present data on anxiety as a risk factor for increased and prolonged symptoms of concussion Provide recommendations for co-management of potential symptoms of anxiety following concussion 1

2 CBT for Child/Adolescent Anxiety Disorders Currently, CBT is the only therapy for child anxiety deemed well established and first-line treatment based on review of over 30 methodologically robust or fairly rigorous studies (Higa-McMillan et al., 2016) Exposure as primary active ingredient for many disorders (Deacon & Abramowitz, 2004) Evidence-Based CBT: Anxiety Disorders Effective CBT for ANXIETY DISORDERS generally involves the following essential or active ingredients (Silverman, 2008; Rapee et al., 2009): 1. Psychoeducation 2. Relaxation training (sometimes optional) 3. Cognitive Identification & Modification 4. ***Exposure (helping individual to gradually confront previously avoided situations until habituation / mastery)*** Hence, the above are evidence-based, and school-based interventions and accommodations should include them and be guided by their principals. To partner with families, the above can be termed active coping skills Summary of Green et al., 2016 School Functioning and Use of School-Based Accommodations by Treatment- Seeking Anxious Children 1. School is an especially salient stressor for most children with anxiety. Excessively anxiety negatively affects two broad areas: academic and social functioning. 2. Accommodations for anxiety should be evidence-based 3. Many accommodations as written are vague 4. Many accommodations are not evidence-based in that they encourage anxious avoidance 5. Accommodations that encourage anxious avoidance are neither evidence-based nor helpful in the long-term for a child with excessive anxiety. 2

3 General Strategies for Health Care Providers to Relay to Caregivers Regarding Anxiety In general, avoidance / delay / escape / rumination strategies shorten anxiety in the short term, but maintain it over time. Health care providers working with school personnel can be of significant help with regard to normalizing anxiety, helping children and parents develop plans for managing anxiety at school, and encouraging active coping on a day-to-day basis. Katherine Dahlsgaard, Ph.D. Anxiety: diathesis for PCS? Pre-injury: Baseline anxiety and stress correlated with greater number of selfreported concussive symptoms and worse severity (Edmed & Sullivan, 2012; Putukian et al., 2015) Anxiety: diathesis for PCS? Post-injury: Anxiety sensitivity concurrently associated with increased symptoms of concussion among adults (Wood et al., 2011) Pediatric patients with premorbid anxiety diagnosis and/or treatment predicted increased postconcussive symptoms (Kirkwood et al., 2014) Anxiety post-injury concurrently and prospectively associated with more severe self-reported symptoms of concussion (King, 1996) 3

4 Anxiety: diathesis for PCS? Recovery: Corwin et al. (2014) Pediatric patients with premorbid anxiety took 2.3x longer become symptom free (168 days vs. 76 days) ALL these patients took > 4 weeks to recover, required school accommodations, and reported declining grades Patients with pre-existing anxiety or depression tend to have prolonged course, delayed resolution of symptoms Direction of causality unclear Symptoms of PCS maybe secondary to mood/anxiety disorder itself rather than traumatic brain injury A possible mechanism Negative interpretations & predictions CONCUSSION Heightened symptom sensitivity Increased symptoms (anxiety, PCS, both??) A possible mechanism CONCUSSION I really need to stay home so this doesn t get worse. ANXIETY Heightened symptom sensitivity AVOIDANCE Increased symptoms (anxiety, PCS, both??) 4

5 Anxietyprovoking situation, such as taking a test, going to school, or even just feeling anxious A tale of 2 treatments Symptoms of anxiety Enhance approach to feared situations (i.e., exposure) Return to functioning dependent on symptom INCREASE (at least at first) Symptoms of concussion Restriction of physical and cognitive activities Return to functioning dependent on symptom DECREASE General Strategies for Health Care Providers to Relay to Caregivers Regarding Anxiety, cont... In general, it is most helpful to emphasize that the purpose of accommodations for anxiety is: To teach a child distress tolerance this can also be termed resilience To help the child to function better over the long-term lessons for a lifetime function better and resilience do not equal doesn t feel anxious The following are some specific evidence-based strategies you can enact with kids or recommend to parents Katherine Dahlsgaard, Ph.D. 5

6 1. Psychoeducation About Anxiety For Caregivers Active coping skills = Psychoeducation becoming an expert about anxiety Relaxation skills learning how to relax herself so he can face his fears with more confidence Cognitive ID and modification recognizing unhelpful anxious thoughts & bossing them back Gradual exposure gradually facing his fears so he learns she can not only cope, but thrive help him to tolerate distress increase his resilience develop confidence through learned experience Katherine Dahlsgaa rd, Ph.D. 1. Psychoeducation about Anxiety FOR STUDENTS 1. Normalize - anxiety is the most common problem in kids. Up to 1 in 3 has anxiety that gets in the way or messes things up. 2. Explain difference between normal vs. problematic anxiety: mild anxiety is cool but maybe you have too much of a good thing 3. Explain the 3 domains of anxiety False Alarm of body, brain, and behavior 4. Instill hope: Anxiety is best managed by learning and practicing active coping skills NOT THROUGH MAGIC or trying to make it go away. Psychoeducation regarding physiological symptoms Anxiety > heart rate respiration quickens/deepens chest tightness shortness of breath muscle tension perspiration GI distress dry mouth bladder relaxes depersonalization fatigue headache dizziness sleep disturbance difficulty concentrating nausea blurry vision irritability sadness Concussion / PCS slowed mentation confusion In a fog drowsiness light & noise sensitivity forgetfulness vomiting tinnitus balance problems 6

7 Psychoeducation regarding anxiety post-injury Importance of early psychoeducation Normalization of symptoms Benign, time-limited nature of any sustained neuropathology Anxiety as understandable and expected Instill expectations for positive recovery Symptoms will ultimately improve; bumps along the road are expected and don t warrant a global, stable, catastrophic interpretation functioning / approach / coping less anxiety (unnecessary) avoidance more anxiety 2. Relaxation Training: Slow Breathing & Progressive Muscle Relaxation can be taught, but must be practiced during non-anxious situations Mindfulness exercises are also increasingly supported by the literature A child does not have to feel completely relaxed in order to function when stressed. In fact, she shouldn t feel completely relaxed! 2. Relaxation Training: Yerkes-Dodson Curve Katherine Dahlsgaar d, Ph.D. 7

8 Katherine Dahlsgaa rd, Ph.D. 3. Cognitive Identification & Modification Cognitive Bias = unhelpful thinking or catastrophic thinking 1. Distortions of probability anxiety exaggerates the likelihood of something bad happening 2. Distortions of severity anxiety predicts DIRE 3. Distortions of consequences competence anxiety UNDER-predicts our ability to cope if something does go wrong Note: Often, kids don t know what they are anxious about. That s okay! Proceed to graded exposures! A possible mechanism I m never going to be the same again. CONCUSSION Heightened symptom sensitivity Increased symptoms (anxiety, PCS, both??) 4. EXPOSURE: The Most Important Ingredient What children and caregivers will learn from graded exposures: Exposures = skill rehearsal, planned rehearsal brave practice practice conquering your fears Anxiety in anticipation of exposure may be higher than anxiety during actual exposure Anxiety is transient Feared consequences are highly unlikely to materialize Avoidance strengthens fear; facing fear (exposure) weakens it 8

9 EXPOSURE (i.e., bravery practice) Exposure to fear-eliciting stimuli or situations Prevention of avoidant behaviors Foster adaptive coping and processing of new learning/corrective information Gradual habituation to symptoms over time, repeated trials From Dugas & Robichaud (2007) Combining Accommodations & Exposure Accommodations should be No more than needed Individualized and specific Time-limited Designed to minimize effect of secondary gain Evolving 1 st return to regular, structured routine Then hierarchy, depending on symptoms E.g., Out for 1 st week, ½ time during 2 nd week, full days with limited homework during 3 rd week, full return by 4 th week of Gradual Exposure Plan for Test Anxiety Example of Exposure Hierarchy Situation Distress Rating Taking test at home 4 Taking test at school, but after class 5 Taking test during class, but I can come back and finish the parts I didn t get to after class 5 Taking test during class, but it isn t graded 7 Taking test during class 8 Katherine Dahlsgaard, Ph.D. 9

10 Katherine Dahlsgaa rd, Ph.D. Evidence-Based Intervention: Contingency Management (Rewards for Brave Behaviors) Never be afraid to REWARD brave behaviors Rewards are not bribes Rewards are there to motivate healthy behavior and the acquisition of skills They don t have to be big, they just have to be motivating Removal of privileges until a brave behavior is performed? Yeah, that s good caregiving. Avoid Expecting the child to do something scary for free or just because you think s/he should. Instead. Have the reward established in advance, part of the plan, and preferably ready to be awarded as soon as the brave behavior is performed Psychosocial Recommendations: Recovery Given the disruptive nature that concussion symptoms may pose for the student and his or her family, adding additional restrictions that may not be needed has the potential to create further emotional stress during recovery. This calls for an individualized approach for the student when a pediatrician is making recommendations for cognitive rest and the student s RTL in the school setting. (Halstead et al., 2013) QUESTIONS? 10