Youth with Anxiety and Depression

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Youth with Anxiety and Depression


CBT is the treatment of choice for a range of disorders and problems in childhood. The focus on self-rewards (positive reinforcement), goal setting, behavioral modification, and skills training makes CBT a natural intervention for children. Although most parents turn into amateur CBT therapists as we try to encourage and shape positive behaviors in our children and extinguish negative ones (classic behavioral therapy terms), professional help is often still needed. Age seven is generally considered an appropriate age for starting CBT, but some children less than seven can benefit from some aspects of CBT.


This chapter and the following, Chapter 13, present examples of several successful CBGT approaches to treating and supporting anxious and depressed children and adolescents. Challenges in successful implementation of CBGT include the role of parents and the degree to which different disorders and different ages can be mixed into the same group. For younger children, it seems obvious that the parents become a key part of treating children given children’s dependency on their parents and home environment. However, for older children, the role of peers may be more important than that of parents. A group format may therefore be especially helpful for children ages 12 and above.


Anxiety and Depression in Children and Adolescents


Childhood anxiety disorders are common, with estimates that about 10% of school-age children suffer from one or more (Reynolds, Wilson, Austin, & Hooper, 2012). The most frequent types of anxiety in children include social anxiety, generalized anxiety disorder (GAD), panic disorders, obsessive–compulsive disorder (OCD), and separation anxiety. All of these disorders are described elsewhere in this book (Chapters 1, 7, 8, and 13), except for separation anxiety.


Separation Anxiety Disorder is now listed under Anxiety Disorders in the DSM-5 (APA, 2013).1 According to the DSM-5, separation anxiety disorder involves at least three of the following eight symptoms: recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures, worry about losing attachment figures or about possible harm to them, worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident), reluctance or refusal to be away from home and go to school or work because of fear of separation, fear of being home alone without attachment figures, reluctance or refusal to sleep away from home, nightmares involving the theme of separation, and complaints of physical symptoms (e.g., headaches, stomachaches, nausea) when separation from attachment figures occurs or is anticipated. In order to be diagnosed, the problems must last at least 4 weeks in children and at least 6 months in adults and must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.


Untreated anxiety of any kind in children can interfere significantly with academic and vocational achievements, as well as with achieving satisfying peer and family relations. Social isolation is one of many devastating consequences of untreated anxiety. Although the focus has primarily been on developing effective treatment for childhood anxiety, depression also often develops as a result of or secondary to the anxiety. Protocols targeting depression will, therefore, also be reviewed in this chapter. Although these protocols recognize the overlap between anxiety and depression, they can also be used for children who seem to only struggle with depression.


Child-Focused CBT


For children, CBT has for decades been recognized as a preferred treatment option to medication. Because the long-term effects of antidepressant and antianxiety medications for children are yet unknown, most parents are reluctant to agree to pharmacotherapy for young children. Although other forms of psychotherapy, such as psychodynamic (Target & Fonagy, 1994), are also effective, they usually take longer to achieve desired outcomes. 12–16 sessions of CBT is often sufficient for children to make impressive changes—provided they spend time practicing what they learn in sessions. CBT thus has a cost-effective advantage, which is important when the goal is to offer help to as many children and families as possible.


A number of trials—including some randomized controlled ones—comparing individual and group CBT to other forms of treatment or placebo treatments have consistently yielded strong support for both individual and group CBT in children (e.g., Manassis et al., 2002; Mendlowitz et al., 1999; Reynolds et al., 2013; Silverman et al., 1999). These studies all contribute to the growing popularity for CBT as an effective treatment, especially of CBGT for older children. Indeed, there is some evidence that CBGT may lead to better maintenance of treatment gains 1 year after treatment compared to individual CBT (Flannery-Schroeder, Choudhury, & Kendall, 2005). On the other hand, there are also some child anxiety disorders that may not respond as well to a group format.


The child-focused CBT manuals for anxiety disorders include, to name the most widely used, the American Coping Cat program (Kendall, 1990), the Australian Coping Koala program (Barrett, 1995), the Canadian Taming Worry Dragons program (Garland & Clark, 2009), the Australian Freedom from Obsessions and Compulsions Using Special tools (FOCUS) program (Barret, Healey-Farrell, & March, 2004), and the Australian FRIENDS program (Barrett, Shortt, Fox, & Wescombe, 2001). These protocols all offer a number of similar CBT strategies and techniques about what to do when adapting CBT to younger people, but less about how to do it. Clinicians are often left struggling with figuring out the best process for delivering CBT to younger persons. Simply taking an adult CBT protocol and trying to extend it downward to children does not work well. Not only do children become bored, but this also fails to acknowledge important developmental issues that need to be taken into account in child-focused CBT. In his excellent clinician guide, Paul Stallard (2005) addresses a number of process issues regarding CBT for children, such as when and how to include parents, how to present adult-based techniques in a simpler and more fun way, and when to emphasize behavioral interventions over cognitive ones. Although Stallard primarily deals with individual CBT, many of his suggestions can be woven into the group format, as this chapter will show.


The role of parents


As for the role of parents, the child-focused CBT approaches we will be discussing do this in different ways. Raising children is at best humbling. The saying “I was a great parent until I had kids” resonates with many. Thus, parents readily admit to feeling helpless, and it is not difficult to get at least one parent interested in learning more about their child’s CBT and how to best offer support. Clinicians seem to differ in their opinions about the helpfulness of involving parents. The older literature is more critical of the involvement of parents (King et al., 1998; Toren et al., 2000), whereas newer studies are supportive. However, a meta-analysis of 55 studies of high-quality randomized controlled trials of psychological therapies for anxiety disorders in children and youth concluded that parental involvement in the child’s therapy was not associated with differential effectiveness (Reynolds et al., 2012). Despite this meta-analytic study conclusion, several clinical research trials on treating anxious children show that the involvement of parents makes a positive difference.


Barrett, Dadds, and Rapee (1996) treated 79 children with anxiety individually using a variation of the Coping Koala CBT protocol. They found that parental involvement in children’s anxiety treatment resulted in 95.6% of children being declared diagnosis-free after treatment, compared to 70.3% for children whose parents were not involved. The involvement of parents in this study consisted of their being enrolled in separate, parallel parent sessions where they were taught how to reward their children when they engage in courageous behaviors, how to not encourage excessive anxiety, how to deal with their own emotional upsets, how to gain awareness of their own anxiety in stressful situations, and how to model problem solving. After each separate child CBT and parent anxiety management session, they would come together as a family with a therapist (family anxiety management) and review what they had each learned and discuss new skills and how they would resolve hypothetical ambiguous situation (e.g., “On the way to school, you (your child) feel(s) funny in the tummy. What do you think is happening? What would you (your child) do?”). The positive effect of parents’ involvement was stronger for the younger children and for girls.


In another study on parental involvement in individual CBT for children ages 12–17 with OCD, the parents attended every session along with their children, that is, the parents were coclinicians. Although both groups, children alone and children with family, achieved significant reductions in symptoms of OCD, the parent-involved group did better (Reynolds et al., 2013). The way in which clinical trials include parents obviously differs, which may have contributed to the lack of a significant finding in the Reynolds meta-analysis (Reynolds et al., 2012).


Parents can be involved in various ways. They can be (a) facilitators, (b) coclinicians, or (c) clients in their own right (Stallard, 2005). The parental facilitator role is the least involved and usually consists of offering the parents a few sessions separate from and in parallel with those of their children. The focus is on educating the parents about the CBT model and the specific skills the children are learning. When parents are coclinicians, they attend a number of sessions in the same group as their children, and they play an active role in encouraging and monitoring homework between sessions. Parents can also be clients themselves, as we saw earlier in the Barrett study, and attend sessions without their children. In those sessions, parents are taught skills to help them better manage their children’s behaviors, problem solve, and negotiate with their children. These sessions also deal with parental thinking styles and help correct any unhelpful beliefs regarding attribution (e.g., “My child not wanting to go to school has absolutely nothing to do with me or us as parents”) or about the origins of the problem (“She is refusing school to get back at me”). The focus in these sessions inevitably becomes the parents’ own anxiety and how this may impact their response to and management of their child’s anxiety. This will be further addressed in the discussion on a specific CBGT protocol for anxiety.


Before delving into the various CBGT manuals, a note on the limitation of CBT for childhood problems seems fitting. CBT is not a panacea for all childhood disorders. Child-focused CBT is especially suitable for the childhood internalizing disorders such as depression, GAD, social anxiety, separation anxiety, and school refusal. In regard to externalizing disorders, such as attention deficit hyperactivity disorder (ADHD), aggression, and anger, the evidence for child-focused CBT is less strong.


However, CBT may be part of a comprehensive treatment approach toward externalizing problems. Such approaches usually involve a parent education component. Using CBT, parents learn how to set limits on their children’s behaviors, how to show consistency, and how to reward adaptive and positive behaviors. CBT is also insufficient when there are larger family system issues at play. For example, the child’s behavior may become the focus that unites and diverts the parents’ attention away from their own relationship conflicts. A not uncommon example is of a 12-year-old child who is scared of sleeping alone in his own bed and insists on being in the parental bed. He may have overheard the parents arguing many a time in their bed and thus attempt to be a peacekeeper. This of course prevents the parents from addressing their own intimacy issues as they focus on their “anxious” child. Or a child’s “distorted” thinking about being overly criticized, rejected, or not supported and loved may prove to be a reality. In such cases involving other struggling family members, there is a risk of the therapist colluding with an unwell family and mistakenly pathologizing the child (Stallard, 2005).


CBGT for children and adolescents with anxiety


It has been encouraging to follow the developments in CBGT for children. For younger people, belonging to a group of peers where one feels accepted contributes greatly to healthy psychological development. However, the actual group climate likely matters in different ways for different ages. For younger children, support and praise from parents and group therapists may be more important than for older children. For children ages 12 and above, although parental and therapist support and praise are necessary, this is rarely sufficient. Peers matter, and the group format with all its opportunities for bringing out that sense of connection and togetherness allows CBT to become even more popular at a time when childhood mental health problems are on the rise. Groups for children tend to be transdiagnostic and include various anxiety disorders in the same group. Similar to adults, however, OCD does not mix so well with other anxiety disorders and is best treated in a separate group. Chapter 13 outlines a CBGT approach for youth with OCD.


Barrett (1998) developed the first study on the efficacy of CBGT for children ages 7–14 with anxiety disorders, including separation anxiety, generalized anxiety, and social anxiety. The children were randomly assigned to three groups: CBGT alone, CBGT plus family management, and a wait list. The number of children who no longer met diagnostic criteria for an anxiety disorder after treatment was significantly higher for those in the treatment groups—with 85% no long symptomatic in the CBGT group and 65% in the CBGT plus family management. For those on the wait list, only 25% improved. These clinical outcome studies led to the creation of the program called FRIENDS, a family- and peer-based CBGT program for anxious children. The program consists of 10 weekly sessions and two booster sessions at 1 and 3 months following completion of the group treatment. Although initially designed for school-age children in Australia, the FRIENDS program is now widely used in the United States, Canada, and—with translation—various European countries, including Holland, Germany, Belgium, and Portugal (Shortt, Barrett, & Fox, 2001).


The name FRIENDS is an acronym for the strategies taught: F, feeling worried; R, relax and feel good; I, inner thoughts; E, explore plans; N, nice work so reward yourself; D, don’t forget to practice; and S, stay calm, you know how to cope now. The FRIENDS program encourages children to (a) think of their body as their friend because it tells them when they are feeling worried or nervous by giving them clues; (b) be their own friend and reward themselves when they try hard; (c) make friends, so that they can build their social support networks; and finally (d) talk to their friends when they find themselves worrying about difficult situations (Shortt et al., 2001).


Similar to other anxiety programs for children, such as Coping Cat and Taming Worry Dragons, FRIENDS is based on core CBT interventions, such as exposure, relaxation, cognitive strategies, and contingency management (self-rewards). In addition, the FRIENDS program has some unique features. The program recognizes that cognitive abilities vary in younger children compared to older children, and it therefore comes in two forms: FRIENDS for children (ages 6–11) and FRIENDS for adolescents (ages 12–16). The FRIENDS program explicitly incorporates a family skills component, which includes helping parents cope with their own anxiety, communication and problem-solving skills, as well as how to offer positive reinforcement to their children. Strategies for how families can build supportive social networks are emphasized. Parents and children are encouraged to practice the skills learned in FRIENDS as a family on a daily basis.


The developers of the FRIENDS program reasonably assumed that cognitive strategies would be most attractive and effective for adolescents, whereas behavioral and self-reward strategies would be more effective for younger children. However, the clinician expectations were not fully born out (Barrett et al., 2001). Parents of younger children rated identifying inner thoughts (cognitive strategy) as more useful for their child than did parents of adolescents. The younger children and the adolescents themselves did not differ significantly in their ratings. But the younger children found the behavioral techniques with self-reward to be the most useful. Contrary to expectations, the adolescents also rated the behavioral technique of developing a graduated exposure hierarchy to be more useful than the cognitive techniques. This finding of behavioral preferences is consistent with our experience in youth OCD groups, which I discuss in Chapter 13.


Similar to other CBGT programs for children, the developers of FRIENDS encourage clinicians to emphasize a number of group process factors. These take the form of group exposure through discussion, role-playing common threatening experiences, and group conversations about successes and difficulties. I have already stated in previous chapters that a CBGT format lends itself especially well to the more behavioral and doing parts of CBT. With this in mind, it may be less surprising that the behavioral exercises resonated with the FRIENDS adolescents and allowed them to form lasting positive memories, which likely influenced their later evaluation of their group experience.

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Jan 6, 2017 | Posted by in PSYCHOLOGY | Comments Off on Youth with Anxiety and Depression

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