Applying cognitive-behavioral therapy for anxiety to the younger child

Anxiety and depression from age 3 to 8 years in children with and without ADHD symptoms

Childhood anxiety and depressive symptoms may be influenced by symptoms of attention deficit/hyperactivity disorder (ADHD). We investigated whether parent- and teacher-reported anxiety, depressive and ADHD symptoms at age 3 years predicted anxiety disorders and/or depression in children with and without ADHD at age 8 years. This study is part of the longitudinal, population-based Norwegian Mother, Father and Child Cohort Study. Parents of 3-year-olds were interviewed, and preschool teachers rated symptoms of anxiety disorders, depression and ADHD. At age 8 years (n = 783), Child Symptom Inventory-4 was used to identify children who fulfilled the diagnostic criteria for anxiety disorders and/or depression (hereinafter: Anx/Dep), and ADHD. Univariable and multivariable logistic regression analyses were used. In the univariable analyses, parent-reported anxiety, depressive and ADHD symptoms, and teacher-reported anxiety symptoms at age 3 years all significantly predicted subsequent Anx/Dep. In the multivariable analyses, including co-occurring symptoms at age 3 years and ADHD at 8 years, parent-reported anxiety and depressive symptoms remained significant predictors of subsequent Anx/Dep. At age 3 years, regardless of ADHD symptoms being present, asking parents about anxiety and depressive symptoms, and teachers about anxiety symptoms, may be important to identify children at risk for school-age anxiety disorders and/or depression.

Reducing Aggression Using a Multimodal Cognitive Behavioral Treatment Approach: A Case Study of a Preschooler With Oppositional Defiant Disorder

Individual cognitive behavioral therapies (CBT) have been shown to be effective in decreasing disruptive behaviors in children and adolescents; however, less is known regarding their efficacy with preschoolers given the developmental limitations accompanying this age range. The current case study extends the use of individual CBT to a preschool aged girl with oppositional defiant disorder (ODD), and is the first to investigate its efficacy in combination with behaviorally-based parent training and classroom teacher consultation. A total of 18 CBT sessions with the child and her parents, in addition to school observations and on-site and phone consultations with teachers, were conducted over a 4-month period. Post-treatment and 2-month follow-up assessments demonstrated significant decreases in physical aggression and property destruction, as well as for parent and teacher reported internalizing and externalizing symptoms. Collectively, results of the case study provide preliminary evidence that a multimodal approach can be applied effectively to treat behavioral problems in preschool-age children.

Very early family-based intervention for anxiety: two case studies with toddlers

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive-behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent-child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

Nash-wo-Numa (childhood growth & development) study protocol: factors that impact linear growth in children 9 to 15 years of age in Matiari, Pakistan

INTRODUCTION

Adolescence is a time of significant physical and emotional change, and there is emerging concern that adolescents living in low- and middle-income countries (LMIC) may face substantial challenges in relation to linear growth and mental health. Data on the global burden of stunting after 5 years of age are limited, but estimates suggest up to 50 per cent of all adolescents in some LMIC are stunted. Additionally, many LMIC lack robust mental health care delivery systems. Pakistan has one of the world's largest populations of adolescents (10 to 19 years) at approximately 40 million. The Nash-wo-Numa study's primary objective is to assess the prevalence and risk factors for stunting among early adolescents in rural Pakistan. The study also aims to determine the prevalence of poor mental health and identify factors associated with common mental health concerns during the childhood to adulthood transition.

METHODS

This cross-sectional study will include girls (n= 738) 9.0 to 14.9 years of age and boys (n=687) 10.0 to 15.9 years of age who live in the rural district of Matiari, Pakistan. Participants will be assessed for anthropometrical measures, puberty development, nutritional biomarkers as well as symptoms of depression, anxiety and trauma using validated scales.

ETHICS AND DISSEMINATION

The proposed study aims to complete the picture of child and adolescent health concerning linear growth and mental health by including puberty indicators. Ethics approval has been granted by the Ethics Review Committee at the Aga Khan University, Karachi, Pakistan, #5251-WCH-ERC-18 and Research Ethics Board at SickKids Hospital, Toronto, Canada, #:1000060684. Study results will be presented at relevant conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03647553; Pre-results.

Anxiety and Interpretation of Ambiguity in Autistic Children, Typical Children and Their Mothers

Anxiety is highly prevalent in autistic children. Yet interpretation biases implicated in anxiety in non-autistic individuals have received little research attention in this group. Twenty-two autistic children and 25 typical children completed an ambiguous scenarios interview and questionnaire-based measures of anxiety. A subsample of mothers completed parent-report and adult relevant versions of the interview and anxiety questionnaires. Autistic children self-reported similar interpretations of ambiguous scenarios, and similar levels of anxiety, to their typical peers. In contrast, mothers of autistic children reported greater levels of anxiety, and more negative interpretations of ambiguous scenarios in both their children and themselves, relative to mothers of typical children. These data highlight the importance of including autistic children's self-reports when measuring and treating anxiety.

My First Time Hurt: Using Preschool PTSD Treatment to Address PTSD Symptoms in a Young Girl With a History of Pediatric Cancer

This case study followed a 4-year-old Caucasian female in cancer remission who presented with symptoms of posttraumatic stress disorder (PTSD). Given the age of this young girl and the health difficulties that she experienced, the preschool PTSD treatment (PPT) manual was implemented to address her distressing symptoms. In addition, it was important to include this young girl’s primary caregiver at each step of the treatment process. Following treatment, this young girl demonstrated significant improvement in her symptomology, as measured quantitatively and qualitatively. Further, this young girl was able to utilize the skills and techniques that she learned and generalize them to other circumstances that caused discomfort or emotional difficulty for her. This case study also demonstrated that incorporating intensive parental involvement with PPT can further the reduction of PTSD symptoms in young children who have experienced medically related trauma.

Play-Modified One-Session Treatment for Young Children with a Specific Phobia of Dogs: A Multiple Baseline Case Series

The one-session treatment (OST) approach for SPs is deemed well-established, and has been found to be highly effective for older children and adults; however, has not yet been trialled with very young children. The present study examines the preliminary effectiveness of play-modified OST for young children with a SP of dogs, using a multiple baseline controlled case series design. Treatment involved play modified one-session of intensive cognitive-behavioural therapy (OST plus Play) which was followed by brief telephone delivered maintenance calls over the 3 weeks immediately following treatment. Four young children (4 years of age) participated and symptoms were assessed at pre-treatment, across a 1-3 week baseline phase, immediately following the OST plus Play, and at 1 and 3 months follow-up. Visual inspection provided evidence for stability of symptoms across the baseline phase, followed by reductions in symptoms over the course of treatment and follow-up. Non-parametric analyses offered further support, with significant improvements in following the intensive OST plus Play intervention.

Efficacy and Acceptability of Psychotherapy for Anxious Young Children: A Meta-analysis of Randomized Controlled Trials

We aimed to provide an overview of psychotherapy in young anxious children (mean age, <7 years). Seven electronic databases, including PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, and ProQuest Dissertations, were searched. Randomized controlled trials that compared psychotherapies with control conditions were included. Efficacy (score change on an anxiety rating scale and rate of being freed from anxiety) and acceptability (discontinuations due to any event) were evaluated. Six of the total seven studies included in our study adopted cognitive behavioral therapy (CBT), with only one adopting behavior therapy (BT). Psychotherapy effectively reduced anxiety symptoms (standardized mean difference = -0.83; 95% confidence interval [CI], -1.08 to -0.57), and its rate of freeing patients from anxiety was high (risk ratio [RR] = 0.30; 95% CI, 0.19 to 0.47). No remarkable difference for acceptability was found between the two therapy types (RR = 0.54; 95% CI, 0.25 to 1.18). Psychotherapy, both CBT and BT, benefits young anxious children.

Cognitive Behavioral Therapy in a One-Session Treatment for a Preschooler With Specific Phobias

Anxiety disorders among preschool-aged children are as prevalent as in older children, yet younger children are even less likely to receive treatment for these frequently impairing childhood disorders (Egger & Angold, 2006). Specific phobias (SPs) are often the earliest form of anxiety to onset, affect 2.3% of preschoolers (Egger & Angold, 2006), and tend to be stable from 3 years of age to at least 6 years of age (Bufferd, Dougherty, Carlson, Rose, & Klein, 2012). Recently, our group developed and piloted a modified intensive one-session treatment (OST) incorporating play therapy for preschoolers with SP (Farrell, Kershaw, & Ollendick, in press). Given that highly fearful young children may find concentrated, rapid exposure therapy highly confronting, we integrated play therapy into the commencement of this treatment to (a) assist with rapid rapport building with the therapist and (b) enhance the child's motivation through engaging them with play. An initial, controlled, baseline case series (N = 4) provided preliminary evidence of the feasibility, acceptability, and effectiveness of this innovative one-session (3 hours) therapy-POP! Pre-schoolers Overcoming Phobias (POP; Farrell et al., in press). The approach combines child-centered, nondirective play therapy (during Hour 1) and empirically supported OST (during Hours 2 and 3), with 4-year-old preschool children with clinical SPs of dogs. This article presents a case description of POP, describing the assessment approach, cognitive-behavioral case formulation, and intensive treatment of a 4-year-old girl who presented with a severe SP of dogs, along with various other comorbid SPs.

Cognitive-behavioral versus non-directive therapy for preschoolers with severe nighttime fears and sleep-related problems

OBJECTIVE

To compare the efficacy of a developmentally appropriate cognitive-behavioral therapy protocol for preschoolers with severe nighttime fears and sleep-related problems, with an active control treatment.

METHODS

Ninety children aged four to six years (63% boys) with severe nighttime fears and their parents were randomized to either cognitive-behavioral therapy including parent involved play (CBT-PIP) or to a structurally equivalent non-directive treatment (TEPT; triadic expressive play therapy). Treatment conditions were also equivalent in parent- and child-rated credibility and expectancy, and in therapist-rated compliance. Children and parents were assessed at baseline, during the first intervention week and four weeks after treatment. Measures included actigraphy, daily sleep logs, structured diagnostic interviews and parent questionnaires.

RESULTS

Significant reductions were observed in nighttime fears and objectively and subjectively measured sleep disruptions in both intervention groups following treatment. Parent reports indicated more advantageous outcomes for CBT-PIP compared to TEPT, with greater reductions in sleep problems and co-sleeping as well as higher customer satisfaction in the former group.

CONCLUSIONS

While CBT-PIP showed no significant advantage compared to the active control in reducing fears or in improving objectively measured sleep, it was significantly more beneficial in reducing the adverse behavioral features of nighttime fears.

Socratic Questions With Children: Recommendations and Cautionary Tales

This clinically focused article offers cognitive behavior therapists recommendations and cautionary tales for using the Socratic method when working with children. The importance of the therapeutic relationship in combination with developmental considerations is discussed. The use of Socratic method in various cognitive behavioral modules is illustrated by means of case examples. Dialogues provide examples of how the cognitive specificity hypothesis and downward arrow technique can be used to support young clients in eliciting negative automatic thoughts. The importance of pacing, the mixing of closed and open-ended questions, and behavioral experiments to aid cognitive restructuring are also highlighted through extracts from clinical conversations. Finally, the article emphasizes that the purpose of the Socratic method is to broaden thinking and to access new knowledge rather than just giving young clients new thoughts and problem solving strategies.

Preschool PTSD Treatment (PPT) for a Young Child Exposed to Trauma in the Middle East

This case study follows a 5-year-old biracial boy who presented with symptoms of post-traumatic stress disorder (PTSD), separation anxiety, and oppositionality. Cognitive-behavioral therapy (CBT) has been used widely with children to treat a number of anxiety disorders, including PTSD, with success. In the current study, Preschool PTSD Treatment (PPT) was used to treat the symptoms of PTSD in this young boy. After PPT treatment was implemented, he demonstrated significant decreases in his post-traumatic stress symptoms and in his symptoms of separation anxiety and oppositional behavior. In addition, he demonstrated an understanding of and the ability to apply coping and problem-solving skills. Finally, this young boy showed qualitative improvements in academic performance, social interactions, and general emotional and behavioral functioning. This case study added to the growing literature highlighting the utility of using CBT to successfully treat symptoms of PTSD in young children.

Comparison of child-parent and parent-only cognitive-behavioral therapy programs for anxious children aged 5 to 7 years: short- and long-term outcomes

OBJECTIVE

Childhood anxiety disorders (AD) are prevalent, debilitating disorders. The most effective treatment approach for children less than 8 years old requires further investigation. The study's primary objective was to compare 2 cognitive-behavioral therapy (CBT) group programs. CBT was delivered to children 5 to 7 years old and their parents (child-parent) or only to parents (parent-only), whereas children attended group sessions but did not receive CBT.

METHOD

Using a prospective, repeated measures, longitudinal study design, 77 children (29 male, mean age = 6.8 years; SD = 0.8 year) with AD and their parents participated in either a 12-week child-parent or parent-only CBT group treatment after a 3-month no-treatment wait-time. Well-validated treatment outcome measures were completed at 5 assessment time points: initial assessment, pretreatment, immediately posttreatment, 6 months, and 12 months posttreatment. A mixed models analysis was used to assess change in AD severity and global functioning improvements from baseline within each treatment and between treatments.

RESULTS

No significant changes were noted in child-parent or parent-only treatment during the 3-month no-treatment wait time. Both treatments saw significant improvements posttreatment and at longer-term follow-up with significant reductions in AD severity measured by clinician and parent report and increases in global functioning. Significantly greater improvements were observed in the child-parent compared to the parent-only treatment.

CONCLUSION

This study suggests that both parent-only and child-parent group CBT improves AD severity in children 5 to 7 years old. Study results suggest that involvement of both children and parents in treatment is more efficacious than working with parents alone.

Comparison of behavioral profiles for anxiety-related comorbidities including ADHD and selective mutism in children

BACKGROUND

Elucidating differences in social-behavioral profiles of children with comorbid presentations, utilizing caregiver as well as teacher reports, will refine our understanding of how contextual symptoms vary across anxiety-related disorders.

METHODS

In our pediatric anxiety clinic, the most frequent diagnoses and comorbidities were mixed anxiety (MA; ≥ 1 anxiety disorder; N = 155), anxiety with comorbid attention-deficit hyperactivity disorder (MA/ADHD, N = 47) and selective mutism (SM, N = 48). Behavioral measures (CPRS, CTRS) were analyzed using multiple one-way multivariate analyses of covariance tests. Differences between the three diagnostic groups were examined using completed parent and teacher reports (N = 135, 46, and 48 for MA, MA/ADHD, and SM groups, respectively).

RESULTS

Comparisons across the MA, MA/ADHD, and SM groups indicate a significant multivariate main effect of group for caregiver and teacher responses (P < 0.01). Caregivers reported that children with SM are similar in profile to those with MA, and both groups were significantly different from the MA/ADHD group. Teachers reported that children with SM had more problems with social behaviors than with the MA or MA/ADHD groups. Further comparison indicates a significant main effect of group (P < 0.001), such that children with SM have the greatest differences in behavior observed by teachers versus caregivers.

CONCLUSIONS

Clinical profiles between MA/ADHD, MA, and SM groups varied, illustrating the importance of multi-rater assessment scales to capture subtle distinctions and to inform treatment planning given that comorbidities occur frequently in children who present with anxiety.

Recent Advances in Intervention for Early Childhood Anxiety

Anxiety disorders in older children and adolescents have long been acknowledged as impairing, persistent and predictive of future anxiety and mood-related disorders. Until recently, however, anxiety in preschoolers and younger children has been regarded as relatively uncommon and within normal developmental parameters. Increasing evidence is suggestive that symptoms of anxiety in preschoolers parallel those in older children (Hirshfeld-Becker, Micco, Mazirsky, Bruett, & Henin, 2011) with this under-investigated area attracting increasing interest from researchers and clinicians alike. The present review summarises the empirical literature on early intervention and prevention programs for anxiety in young children (aged 3–7 years) with a specific focus on the application of such programs in the school context and implications for guidance counsellors, an improved understanding of which is critical for informing effective intervention. The studies reviewed demonstrate promising outcomes for anxiety; however, there is still a significant amount of work to be done in terms of our understanding of developmentally appropriate, family-focused and child-led models of anxiety and early intervention and prevention protocols.

Evidence-based psychotherapies for preschool children with psychiatric disorders

The field of child and adolescent psychiatry is increasingly aware of the existence of psychiatric disorders in preschool-aged children. Concomitantly, there has been a greater understanding of both the effects of parenting on development as well as how a child's brain is shaped by the environment. There has also been a strong trend toward the use of time-limited, evidence-based therapies in adults and school-aged children, but evidence has been limited regarding the use of interventions to treat psychiatric disorders in preschoolers. In recent years, multiple research groups have worked to create effective psychotherapies for use with preschool populations, and there are also novel applications of existing psychotherapies. This review examines the latest evidence-based psychotherapies that treat preschool children with psychiatric disorders.