Understanding and treating

childhood anxiety

Associate Professor Vanessa Cobham

The University of Queensland

Children’s Health Queensland

Australia

Overview

• What is anxiety?

• Significance of childhood anxiety;

• Aetiology of childhood anxiety;

• The traditional treatment of childhood anxiety and treatment outcome research;

• A new approach to the treatment of childhood anxiety: Working with parents

• Fear-Less Triple P overview

• Fear-Less Triple P evidence base

What is anxiety?

What is anxiety?

• Anxiety is viewed as multi-dimensional

response to the expectation of threat

• Physical, behavioural and cognitive (mental)

components

• Anxiety is common, typically short-lived, and

normal

• Anxiety can be adaptive – we need anxiety

• The goal is to learn to manage anxiety

Anxiety: It’s normal and follows a predictable

developmental progression

• Infancy

• strangers, loud noises, unexpected objects

• 1-2 years

• separation from parents, animals, dark, loud noises, toilet

• 4-6 years

• kidnappers, robbers, supernatural beings

• 6 years - early adolescence

• bodily injury, death, achievement

• 10 years onwards

• social comparison, appearance, personal conduct, exams

Other issues to keep in mind

• Low rate of agreement between parents and children about anxiety symptoms;

• “Feeling sick” – the physical symptoms of anxiety are real;

• Anxious children can slip through the cracks;

• Anxiety in children doesn’t always look the way we expect it to look.

If it’s so normal, how do I know when

anxiety is a problem?

Anxiety becomes problematic

when it frequently:

• Causes significant distress;

and/or

• Interferes with functioning.

A cognitive behavioural model of anxiety

Negative (anxious)

thoughts / interpretations

Physical

Symptoms

Feeling of

anxiety

Behavioural

Response

(avoidance)

Background

Experiences

The significance of clinical anxiety in

childhood and adolescence

Why we need to be worried

What we know

✓ Anxiety in childhood:

✓ Is the most common psychological complaint (~ 1 child per classroom)

✓ Negatively impacts: peer relationships, social isolation, academic performance, school attendance

✓ Impacts the whole family

✓ Is very expensive

✓ Does not get better without treatment

✓ Is a gateway to other problems

✓ Is rarely treated ~18% receive any intervention

N=10,123; Merikangas et al., 2010, JAACAP

Anxiety disorders

Behavioural disorders

Mood disorders

Substance use disorders

Aetiology of childhood anxiety

Hypothesized risk factors for the development and

maintenance of childhood anxiety problems

• Genetic factors

• Temperament

• Stressful life events & potentially traumatic events

• Attachment processes

• Parental influences

• Information processing biases

Environmentally mediated transmission of anxiety: What do we know?

• Recently, a children-of-twins study provided important support “for the direct, environmentally mediated transmission of anxiety from parents to their adolescent offspring over and above any genetic confounding of this association” (Eley et al., 2015, p. 634)

• Parent anxiety creates a family environment that predisposes children to develop anxiety. Thus children may learn anxiety from their parents—for instance, through vicarious learning (Askew & Field, 2008).

• Parent anxiety results in rearing or parenting behaviors that encourage the development of anxiety in children.

• There is a reciprocal relationship between parent and child anxiety, in which children’s anxiety elicits a pattern of parenting that then contributes to the maintenance of their anxiety (e.g., Rapee, 2012).

Treating childhood anxiety

Current ‘gold-standard’ intervention

• Child-focused cognitive behavioural therapy (CBT)

• 10-16 sessions duration typically

• What might it look like?

• Psychoeducation about anxiety

• Cognitive therapy

• Exposure

• Skills acquisition e.g. Problem solving, Relaxation, Controlled breathing

• Other important tools: Reward system, Strengths Bank, Becoming the expert

Child-focused CBT Treatment Outcomes for

Anxiety Disorders: Summary Reviews

• Cartwright-Hatton et al. (2004): Remission rates for CBT higher (56.5%) than for WL (9.1%)and Placebo Control Groups (34.8%) across 16 RCTs

• In-Albon & Schneider (2007): Meta-analysis mean effect size of .86 for CBT; moreover, no differences found between individual vs. group or child vs. family-focused interventions

• Grills & Ollendick (2012) , Reynolds et al. (2012), Wei & Kendall (2014), and Higa-McMillan et al. (2016) confirm these findings in updated reviews

CBT Treatment Outcomes at Follow-up

• Nevo and Manassis (2009): Remission rates maintained at long-term follow-up (2 -7.4 years, 51 - 65%)

• Ginsburg et al. (2014) 6 – yr. follow up of 288 of the 488 CAMS participants: 46.5% diagnosis free (52.0% of responders and 37.6% of non-responders); BUT 48% of responders were NOT diagnosis free at follow-up!

• Conclusions: a significant minority (30-50%) do not respond to CBT and up to 45-50% revert to diagnosis after successful intervention

• Although, LTFU studies are inconclusive due to lack of adequate controls, they are sobering nonetheless

So, we’ve got some work to do…

But treatment outcomes may not be our biggest challenge

The problem of reach

Kazdin (2008) clearly articulated the challenge facing those working with children and adolescents, noting, “the salient issue before us is that we do not reach the vast majority of youth in need with any treatment” (p. 202).

In relation to anxiety specifically, less than 1 in 5 adolescents who meet criteria for an anxiety disorder receive any kind of treatment (Essau, 2005; Johnson et al., 2016; Sawyer et al., 2001).

Some children and adolescents are more likely than others to NOT access treatment.

The majority of anxious youth receive no treatment

<20% receive treatment

>80% receive no treatment

Understanding and addressing barriers

• Financial cost (* lengthier treatments = ed cost)

• Time commitment and convenience

• Parents’ perceptions of:

• Child’s willingness to attend

• Potential benefit & appropriateness of treatment

• Stigma

• Parents view their children as more likely to be stigmatized by others; and more likely to be negatively impacted by this

Key references: Dempster et al., (2013); Jorm & Wright (2007); Reardon et al., (2017); Reardon et al., (2018).

A new approach to the treatment of

childhood anxiety: Working with

parents

What do we know about parent-focused

interventions?• Small number of studies (all with significant methodological problems, disparate interventions, and a

predominant focus on younger children) have examined parent-only clinic-based interventions in the treatment of child anxiety:

• Mendlowitz et al., (1999): family-focused, child-focused, and parent-focused interventions produced comparable outcomes in anxious children aged 7-12 yrs;

• Cartwright-Hatton et al., (2005a,b): reductions in parents’ ratings on Internalizing scale of the CBCL for younger anxious (2-5 & 4-9 yrs) children following parenting skills program;

• Thienemann et al., (2006): significant reductions in the number of anxiety diagnoses met by 24 children aged 7-16 years following a parent-only intervention

• Waters et al., (2009): parent + child and parent-only interventions produced comparable outcomes (both superior to WL) in the treatment of 49 anxiety-disordered children aged 4-8 years;

• Lebowitz et al., (2014): open trial of parent-focused intervention with 10 anxiety-disordered children (9-13-yrs) who had refused individual child-focused therapy; significant reductions on parent-rated symptoms;

• Smith et al., (2014) parent-focused intervention superior to WL with parents of 31 anxiety-disordered (7- 13-yrs) youth; gains maintained at 3-mth f-up.

Fear-Less Triple P

Overview

Evidence base

Conflict of interest / Disclosure statement

The Triple P – Positive Parenting Program is developed and owned by The University

of Queensland (UQ). Royalties are distributed to the Faculty of Health and

Behavioural Sciences at UQ and contributory authors of published Triple P resources.

Triple P International (TPI) Pty Ltd is a private company licensed by Uniquest Pty Ltd

on behalf of UQ, to publish and disseminate Triple P worldwide. The authors of this

report have no share or ownership of TPI. Dr. Cobham may in future receive royalties

and/or consultancy fees from TPI. TPI had no involvement in the study design,

collection, analysis or interpretation of data, or writing of this report. Dr. Cobham is

an employee at UQ.

Fear-Less Triple P

• Triple P – the Positive Parenting Program (Sanders, 2008) – is a multilevel parenting and family support system. Triple P is supported by a significant evidence base (Nowak & Heinrichs, 2008) and incorporates five different levels of intervention intensity, ranging from universal parent information strategies through to enhanced behavioral family interventions.

• Fear-Less Triple P (Cobham & Sanders, 2009; 2015, 2017, 2020) is a suite of programs offering flexibility of delivery in the treatment of childhood anxiety:

• 2-hr universal parent seminar

• 6-week group or individual group

• 1-day workshop

Indicators for Fear-Less Triple P

• Child is 6 to 14 years old and experiences

clinically significant anxiety (distress +

interference)

• Parents view a parent-focused intervention as

acceptable

• Parent can attend the program – the 6-week or

the workshop version

Overview of 6-week program

content

Session description

1. Anxiety: What is it and how does it develop

2. Promoting resilience in children

3. Modelling and the way children think

4. The way you behave: Avoidance and exposure

5. Parental strategies for responding to children’s anxiety

6. Constructive coping – how to promote it and maintaining

gains

Why children become anxious

Learning influences

• Attention and accidental rewards

• Escalation “anxiety-avoidance” trap

• Watching others

• Threatening communication

• Negative expectations

• Not enough opportunities to develop competence

Building Blocks for Resilience:Recognising and accepting feelings

How parents can help:

• Accept different emotions

• Talk about feelings

• Share your own feelings

• Help your children recognise emotions

• Help your children understand the idea of emotion intensity

31

Building Blocks for Resilience:Noticing and celebrating examples of resilience

Help your child to notice and celebrate the times

when they do demonstrate emotional resilience –

the ‘bounce-back’ moments

32

Emotional Resilience Homework taskChild Building Block Specific Actions

Bella

Recognizing and accepting emotions When I am reading with Bella this week, I am going to ask

her how the characters in the story are feeling and how

she knows this.

Max

Expressing feelings appropriately I am going to be on the look out for times when Max

expresses his feelings in an appropriate way and praise

him for this.

Sam

Developing an optimistic outlook Sam and I are going to use the Gratitude Tree app each

day to find things to be grateful for.

The importance of thoughts and becoming a

flexible thinkerEvent/Situation Thought Feelings, physical

reactions &

behaviours

Sean walks into the playground at

school and sees a group of kids from his

class standing around laughing together.

“They’re laughing at me” Worried. Upset. Sad. Feels

sick in the stomach. Heart

racing. Turns around and

walks to the classroom a

different way.

“ “ “Maybe someone has told a

funny joke”.

OK. No physical reactions.

Goes up to the group and

asks what they are laughing

about.

“ “ “They are making fun of

me”.

Angry. Heart racing. Runs up

to the group and starts

pushing kids around.

Mental Gym Exercise

Melanie arrives at work to find a post-it stuck on her computer.

It is from her boss and says:

Using the example below come up with as many different ways

as you can to think about the situation:

See me

ASAP

Why is avoidance so important?

• The short term effects

of avoidance…

• The long term effects

of avoidance…

Exposure

• = A psychological principle

• Addresses the behavioural system – designed to

overcome avoidance

• Involves deliberately & repeatedly placing yourself

in increasingly anxiety-provoking situations;

exposure prolonged until anxiety response is

extinguished.

• Aim = fully experience the anxiety that would

normally result in avoidance & to realise that you

can handle both the situation & the anxiety.

Facing up to fears

Avoidance is the most common behavioural

response to anxiety – it makes sense!

Fear Ladders are the tools we use to help children

face up to their fears in a graduated (step-by-step)

and safe way

Mechanisms underlying exposure

• A fundamental principle underlying the process of exposure is that of habituation.

• If you stay with the feared stimulus for long enough, the anxiety will reduce.

• A reliable phenomenon –inevitably, the anxiety reduces.

• In vivo or imaginal

An exposure hierarchy

1. Identify the feared situation

2. Break the feared situation down into as many different component parts as possible

3. List the components as specifically as possible and rate from 0-100 in terms of its difficulty

4. Rearrange the items in order of increasing difficulty

5. Implement the exposure hierarchy!

Example in vivo hierarchy

A child who is not able to sleep in their own bed

Sleep in my own room. No light.

Sleep in my own room with the hall light on

Sleep in my room with a night light on

Have mum or dad sit with me for 10 minutes and have a night light on

Have mum or dad sit with me till I fall asleep in my own bed and have a night light on

Sleep on a mattress outside mum and dad’s bedroom door

Sleep on a mattress beside mum & dad’s bed

Strategies for dealing with anxietyDoes this apply to me? Is it something I think I want to change?

Tell your child exactly what to do

• Parents will often “direct” an anxious child;

• A vicious circle;

• Usually, parents only adopt this strategy after the

repeated experience of

watching their child be incapacitated by anxiety;

Advantages & disadvantages?

Strategies for dealing with anxietyDoes this apply to me? Is it something I think I want to change?

Prompt your child to cope constructively

• Involves prompting children to think for themselves about how to constructively handle an anxiety-provoking situation;

Advantages & disadvantages?

Constructive Problem Solving

1. What is the problem?

2. Brainstorm all possible solutions

3. What would be the likely consequences if you enacted each solution?

4. Rate how good each set of consequences would be for you

5. Choose the solution that is likely to result in the most positive and the least negative consequences for you

Fear-Less Triple P: Evidence base

Pilot trial

• N = 61 families with a child aged 7-14 meeting criteria for a clinically significant anxiety diagnosis on the ADIS-IV-C/P

• Random assignment to WL or up Fear-less Triple P (delivered as 6-wk group)

• Follow-up points: post, 3-mth, 6-mth & 12-mth

• Outcomes = diagnostic and questionnaire measures (parent and child perspective)

Cobham, Filus & Sanders, 2017.

1 of 5

Fear-Less Triple P: Evidence baseCobham, Filus & Sanders (2017)

0 0

39

0

59

69

84

0

10

20

30

40

50

60

70

80

90

Fear-less Wait list

% of children free of ANY anxiety diagnosis

Pre

Post

3-mth

6-mth

12-mth

2 of 5

Fear-Less Triple P: Evidence base

How low (intensity) could we go?

• N = 73 families with a child aged 7-14 meeting criteria for a clinically significant anxiety diagnosis on the ADIS-IV-C/P;

• Random assignment to 6-wk group or workshop

• Follow-up points: post, 6-mth & 12-mth.

• Outcomes = diagnostic and questionnaire measures (parent and child perspective)

Cobham, Hawkins, Ryan, Ollendick & Sanders, in prep.

3 of 5

Fear-Less Triple P: Evidence base

Some interesting facts about the sample:

• More boys (N=52/73)

• Look the same in terms of anxiety severity, number of diagnoses

• Have more comorbid neurodevelopmental disorders, speech/language

impairments, diagnosed learning disorders and medical conditions compared

to any previous trials

• Families reporting preference for workshop.

Cobham, Hawkins, Ryan, Ollendick & Sanders, in prep.

4 of 5

Fear-Less Triple P: Evidence baseCobham, Hawkins, McLean, Ollendick & Sanders, in prep

0 0

31.0326.66

71.42 71.42

62.5

78

0 00

10

20

30

40

50

60

70

80

90

6-wk gp Workshop

% of children free of ANY anxiety diagnosis

Pre

Post

6-mth

12-mth

5 of 5

Fear-Less

Triple P:

Conclusions

• Conclusions

• The workshop format of Fear-Less is highly

acceptable (arguably preferable) to parents;

• The workshop is producing comparable

diagnostic results to the 6-week program;

• Preliminary data to support use of the

workshop in many other settings, with hard to

reach populations (e.g., Disability Services);

• Our most recent sample is much more

complex than typical trial samples.

• For more information about Fear-Less,

contact Jackie Riach – Jackie@triplep.net.nz

Thank you for wanting to be part of the solution for

anxious kids

Vanessa@psy.uq.edu.au

@DrVanessaCobham