Computerized exposure and in vivo exposure treatments of spider fear in children: two case reports

Symbolic online exposure for spider fear: habituation of fear, disgust and physiological arousal and predictors of symptom improvement

BACKGROUND AND OBJECTIVES

This research compared the effects of real versus hyper-real images on anxiety, disgust, and physiological arousal during internet-delivered exposure in high spider-fearfuls. Hyper-real images were digitally altered to highlight fearful aspects. A further aim was to examine self-reported and behavioural therapeutic outcomes and exposure-related predictors of these outcomes.

METHODS

Twenty-eight females were randomised to real (n = 14) or hyper-real (n = 14) treatment groups and nine participants were subsequently allocated to a wait-list control group. Treatment groups viewed an 8-stage exposure hierarchy of real or hyper-real spider images. Subjective anxiety and disgust ratings were taken during each stage (0, 60, 120, 180 s) with heart rate and skin conductance recorded throughout.

RESULTS

Anxiety, disgust and physiological arousal habituated within each exposure stage, with no differential effect of real compared to hyper-real images. Both treatment groups but not controls demonstrated significant reductions in behavioural avoidance and self-reported phobic symptoms from pre-treatment to post-treatment with large effect sizes noted. The change in within-stage habituation of anxiety, disgust and heart rate, between the first and last stage, predicted improvement in behavioural avoidance at post-treatment. This suggests that generalisation of habituation to multiple images is an important predictor of improvement.

LIMITATIONS

While findings in relation to therapeutic outcome should be considered preliminary, clear relationships were found between exposure-related variables and outcome among those who undertook treatment.

CONCLUSIONS

Findings provide evidence in support of the efficacy of online image-based exposure and have implications for informing further research into the underlying mechanisms of image-based exposure treatment.

Online Exposure for Spider Fear: Treatment Completion and Habituation Outcomes

This research aimed to investigate habituation to spider images during an online exposure treatment (www.feardrop.com) among participants with a high fear of spiders. Participants (N= 392) undertook a 10-stage online exposure treatment with a stage length of either 180 or 360 seconds. Four Subjective Units of Distress Scale (SUDS) ratings were taken throughout each stage. Treatment completion was found to be a significant challenge, with less than one-third (30%) completing at least one stage of the program. Those in the shorter stage length condition were significantly more likely to complete the first stage relative to those in the longer stage length condition (43% vs. 16%). SUDS ratings decreased significantly across time at Stage 1, suggesting habituation of self-reported anxiety and there was an overall reduction in SUDS ratings at the second relative to the first stage, suggesting generalisation of habituation. The greatest habituation was observed among those with high anticipatory anxiety (pre-exposure SUDS rating), high total exposure time, and younger age. There was preliminary evidence for improvement in symptoms of spider fear at post-treatment. Directions for future research include strategies to facilitate treatment completion, evaluation of treatment outcomes, and expansion to include a range of specific fears.

The tripartite model of fear in children with specific phobias: assessing concordance and discordance using the behavioral approach test

Lang's tripartite model posits that three main components characterize a fear response: physiological arousal, cognitive (subjective) distress, and behavioral avoidance. These components may occur in tandem with one another (concordance) or they may vary independently (discordance). The behavioral approach test (BAT) has been used to simultaneously examine the three components of the fear response. In the present study, 73 clinic-referred children and adolescents with a specific phobia participated in a phobia-specific BAT. Results revealed an overall pattern of concordance: correlation analyses revealed the three indices were significantly related to one another in the predicted directions. However, considerable variation was noted such that some children were concordant across the response components while others were not. More specifically, based on levels of physiological arousal and subjective distress, two concordant groups (high arousal-high distress, low arousal-low distress) and one discordant (high arousal-low distress or low arousal-high distress) group of youth were identified. These concordant and discordant groups were then compared on the percentage of behavioral steps completed on the BAT. Analyses revealed that the low arousal-low distress group completed a significantly greater percentage of steps than the high arousal-high distress group, and a marginally greater percentage of steps than the discordant group. Potential group differences associated with age, gender, phobia severity, and phobia type were also explored and no significant differences were detected. Implications for theory and treatment are discussed.

The efficacy of an internet-based cognitive-behavioral therapy intervention for child anxiety disorders

OBJECTIVE

To evaluate the efficacy of an Internet-based cognitive-behavioral therapy (CBT) approach to the treatment of child anxiety disorders.

METHODS

Seventy-three children with anxiety disorders, aged 7-12 years, and their parents were randomly assigned to either an Internet-based CBT (NET) or wait-list (WL) condition. Clinical diagnostic assessment and parent and child questionnaires were completed before and after treatment. The NET condition was reassessed at 6-month follow-up.

RESULTS

At posttreatment assessment, children in the NET condition showed small but significantly greater reductions in anxiety symptoms and increases in functioning than WL participants. These improvements were enhanced during the 6-month follow-up period, with 75% of NET children free of their primary diagnosis.

CONCLUSIONS

Internet delivery of CBT for child anxiety offers promise as a way of increasing access to treatment for this population. Future research is needed to examine ways to increase treatment compliance and further enhance the impact of treatment.

Online CBT in the Treatment of Child and Adolescent Anxiety Disorders: Issues in the Development of BRAVE–ONLINE and Two Case Illustrations

This paper describes the rationale for and development of an online cognitive-behavioural treatment for child and adolescent anxiety (BRAVE–ONLINE). It highlights the challenges involved in adapting a clinic-based intervention for delivery using the internet, with separate sessions for parents and their children (or adolescents). We outline strategies to ensure that young people remain engaged in online therapy, and describe techniques designed to optimize the alliance between clients and the online therapist. Two case studies are presented that illustrate the practical and technical aspects of implementing the intervention, and demonstrate the feasibility of achieving successful outcomes using online delivery of CBT for child and adolescent anxiety. However, firm conclusions regarding the efficacy of this approach cannot be drawn until the results of randomized controlled trials are available. The paper identifies directions for future research.

The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood anxiety

Seventy-two clinically anxious children, aged 7 to 14 years, were randomly allocated to clinic-based, cognitive-behavior therapy, the same treatment partially delivered via the Internet, or a wait-list control (WL). Children in the clinic and clinic-plus-Internet conditions showed significantly greater reductions in anxiety from pre- to posttreatment and were more likely to be free of their anxiety diagnoses, compared with the WL group. Improvements were maintained at 12-month follow-up for both therapy conditions, with minimal difference in outcomes between interventions. The Internet treatment content was highly acceptable to families, with minimal dropout and a high level of therapy compliance.

Twelve-Year Review of In Vivo Exposure: Treating Specific Phobias in Children

This article reviews 15 studies using in vivo exposure to treat specific phobias in children. Six elements of research methods are considered: (a) participants clinically diagnosed; (b) subjective, behavioral, and physiological components of the fear reaction measured; (c) research design; (d) inclusion of a control group; (e) follow-up data collected; and, (f) necessity of including other treatments with in vivo exposure. The studies were obtained through a computerized search of PsycINFO and CISTI This investigation revealed that all six elements of research mc-,ethods examined inthis reiew are in need of improvement. Suggestions for future research in this area are provided.

Computer-aided vicarious exposure versus live graded exposure for spider phobia in children

The efficacy of computer-aided vicarious exposure (CAVE) for the treatment of spider phobia in children was evaluated in a single blind, randomised, controlled trial. Twenty-eight participants, aged 10-17 years, received three 45-min sessions of either Live graded exposure (LGE), CAVE or were assigned to a Waitlist. Phobic symptomatology was measured at pre- and post-treatment, and at one month follow-up on a range of behavioural and subjective assessments. The results showed the superiority of the LGE treatment over the CAVE and Waitlist conditions. Effect sizes support CAVE treatment as being superior to the Waitlist and resulting in reductions of phobic symptomatology.

Computer-assisted therapy: harbinger of the 21st century?

Research findings suggest that computer-assisted therapy (CAT) has the potential to play a significant role in mental health care. Psychoeducation, cognitive-behavioral, and systematic desensitization strategies appear most amendable to CAT approaches. Potential advantages of CAT include an increased number of treatment options, low cost, privacy, consistency and individualization of care, and ease of data collection. Although CAT appears promising, clinician resistance and failure to adequately monitor clients may hamper its use. Moreover, precautions will need to be taken to insure that CAT programs have been well-designed and tested. Nurses should become involved in the development, testing, and implementation of CAT software.

CARL: a LabVIEW 3 computer program for conducting exposure therapy for the treatment of dental injection fear

This paper describes CARL (Computer Assisted Relaxation Learning), a computerized, exposure-based therapy program for the treatment of dental injection fear. The CARL program operates primarily in two different modes; in vitro, which presents a video-taped exposure hierarchy, and in vivo, which presents scripts for a dentist or hygienist to use while working with a subject. Two additional modes are used to train subjects to use the program and to administer behavioral assessment tests. The program contains five different modules, which function to register a subject, train subjects to use physical and cognitive relaxation techniques, deliver an exposure hierarchy, question subjects about the helpfulness of each of the therapy components, and test for memory effects of anxiolytic medication. Nine subjects have completed the CARL therapy program and 1-yr follow-up as participants in a placebo-controlled clinical trial examining the effects of alprazolam on exposure therapy for dental injection phobia. All nine subjects were able to receive two dental injections, and all reduced their general fear of dental injections. Initial results therefore indicate that the CARL program successfully reduces dental injection fear.

Spider phobia in children: disgust and fear before and after treatment

Fear of spiders, disgust sensitivity, and spiders' disgust-evoking status were assessed in a group of spider phobic girls (n = 22) who applied for treatment, in a group of non-phobic girls (n = 21), and in the parents of both groups of children. The phobic girls were tested both before and after behavioural treatment which consisted of 1.5 hr eye movement desensitization and reprocessing and 1.5 hr exposure in vivo. Findings support the idea that disgust is an important aspect of spider phobia: (a) spider phobic girls exhibited higher levels of disgust sensitivity and considered spiders per se as more disgusting than non-phobic girls; (b) there was a parallel decline of spider fear and spiders' disgust-evoking status as a result of treatment; and (c) spiders' disgust-evoking status was relatively strong in mothers of spider phobic girls. The latter finding may indicate, that the acquisition of spider fear is facilitated by specific parental disgust reactions when confronted with spiders.

Spider phobia questionnaire for children (SPQ-C): a psychometric study and normative data

The purpose of this study was to develop a reliable and valid questionnaire to assess spider fear in children. The Spider Phobia Questionnaire for adults was adapted for children by simplifying items and by assessing situations relevant to children. The SPQ for children (SPQ-C) was administered to two non-clinical samples of children aged 8-12. The first sample consisted of 586 Ss who filled in the SPQ-C twice, with a retest interval of 6-7 weeks. Internal consistency and test-retest reliability were high. The second sample consisted of 669 children of which 28 spider phobic and 30 nonphobic girls were selected for the Behavioural Approach Test (BAT). The SPQ-C predicted BAT scores, thus supporting the validity of the questionnaire as a measure of spider fear. Norms for the SPQ-C, based on the total sample of children, are provided.