Cognitive Behaviour Therapy forAnxiety Disorders in Individuals withDevelopmental DisabilitiesKristen McFee, PhDSusan Baer, MD, PhDNov 16 th , 2012Neuropsychiatry Clinic, BC Children’s Hospital
Learning Objectives1. Review the literature on existing treatments for anxiety indevelopmental disabilities.2. Review modifications of traditional cognitive behaviouraltherapy (CBT) protocols for use with persons withdevelopmental disabilities.3. Provide an example of modified-CBT group based treatmentfor anxiety (i.e., Facing Your Fears).
Outline1. Introduction to anxiety in DD (Dr. Baer)2. Review of literature (Dr. Baer)1. Pharmacotherapy2. Cognitive behavioral therapy3. Modified CBT (Dr. McFee)4. “Facing Your Fears” Program (Dr. McFee)
Anxiety Most common psychiatric disorder in children Onset early in life Often lifelong chronic disorders Associated with significant morbidity Kids with developmental disabilities are not immune!
Anxiety: Common in DD Prevalence of Anxiety Disorders in Children: 10-15% general population 15-25% intellectual disability population 50-80% of Autism Spectrum population Suggestion that higher functioning ASD is moreat risk(Bellini, 2004; Russell & Sofronoff, 2005; Simonoff et al., 2008; Skokauskas & Gallagher, 2011)
Anxiety – ImpactUntreated anxiety may interfere with participation inhome, school, and community Learning and classplacement Social skill acquisitionand peer relationships Disruptive behaviour Adaptive functioning Parent/family stress Employment Mental health(Reaven, 2011; Russell & Sofronoff, 2005; Tantum, 2000)
Why so Common?? Biological factors: Fragile brain—increased risk of all Ψ disorders Autonomic system dysregulation (hypersensitivepanic/stress response) Psychological factors: Poor coping skills Poor language skills Social factors: Isolation Increased risk of trauma
Anxiety and ASD High levels of stress due to autism: Lack of ability to “read” social situations makes themmore unpredictable and scary Sensory sensitivities Decreased ability to cope with stress Expressive language difficulties Rigid cognitive style Similar brain pathways underlying ASD and anxiety Amygdala implicated in both ASD and anxiety
Anxiety - Phenotype Symptom presentation: Often complex, multiple anxieties Specific phobias – common; often sensory related, can beidiosyncratic (e.g. fear of bare feet) Social anxiety – appearing “different”, unpredictability,non-social or physical features of social situations Anxiety may present as disruptive behaviour Symptoms of anxiety related to: Increased age Higher cognitive levels Core ASD symptomsShulamite & Ben-Sasson (2010); Thompson et al. (2011)
Diagnostic IssuesBeware of diagnostic overshadowing: misattributing anxiety symptoms to the primary disability (e.g. newonset repetitive behaviors in person with autism interpreted as a “stim”rather than OCD)Language difficulties may limit symptom reportingIndividuals with low IQ may experience anxiety differently: less “worry”, but more “fear”Anxiety symptoms often present non-specifically: insomnia, irritability, hyper-arousal, increased startle response,regression in functioning, outbursts, aggression.Standardized measures may be helpful, but not alwaysavailable
Treatment Issues CBT +/- SSRI’s are the recommended first linetreatment for anxiety disorders in children and adults.Well-researched and documented in the literature. But little information exists on treatment of anxiety ofindividuals with developmental disabilities…. Concern that cognitive/language issues may limitusefulness of CBT in this population Children with DD are more sensitive to medication sideeffects which can limit use of SSRI’s
Medication Trials for Anxiety in DD Small number of studies Mostly open label (i.e. no comparison group) orcase reports Mostly not targeted to a specific anxiety diagnosisbut rather a symptom (e.g. irritability, repetitivebehaviors)
Non-SSRI studies Studies looking at risperidone for behavior difficultiesin ASD have also shown benefit for anxiety symptoms: e.g. Double blind placebo controlled study of risperidone in15 adults with ASD: 28% of pts in risperidone grouplooked less anxious compared with 6% of control group(McDougle 1998) 3 open label studies of buspirone for comorbidanxiety in PDD/DD: 60-70% of people showedimprovement
SSRI Studies Several studies have looked at SSRI’s and ASD Target outcomes vary between studies and haveincluded core ASD symptoms (social/communicationdeficits), repetitive behaviors, irritability, and anxiety Tolerability of SSRI’s has been an issue and there issome evidence that adverse effects (agitation,aggression, hyperactivity, insomnia) may be morecommon than in neurotypical population, especiallyfor children
RCT’s of SSRI’s and ASDMcDougle 1996: N=30 adults with Autism, half treated withfluvoxamine (mean dose 275mg/day). Decreased repetitiveand maladaptive behaviors compared to placebo.McDougle 2000: N=34 children and youth with ASD, halftreated with fluvoxamine (mean dose 100mg/day). Noimprovement; adverse events (insomnia, hyperactivity,agitation) relatively common.Hollander 2005: N=40 children with Autism, half treated withfluoxetine (0.8-2.5mg/kg/day). No change in general autismsymptoms, but decreased repetitive behaviors relative to controlgroup
2 large recent SSRI trialsSOFIA: Study of fluoxetine in Autism (industry sponsored trial)N=160 children and youth with ASD, half treated melt-inmouthfluoxetine (2-14mg). No change in repetitive behaviorsSTAART 2009: Studies To Advance Autism Research andTreatment, N=149 children and youth with ASD, half treatedwith citalopram (mean dose 16mg/day). No change inrepetitive behaviors (primary outcome measure). Irritability wasdecreased.
2010 Cochrane review of SSRI’s and ASD“There is no evidence of effect of SSRIs in children withASD and emerging evidence of harm. There is limitedevidence of the effectiveness of SSRIs in adults fromsmall studies in which risk of bias is unclear.”
Medication Conclusions Start with SSRI’s for treatment of anxiety in DD/ASDpopulation Only use SSRI’s when there is a clear diagnosis ofcomorbid anxiety Start low and go slow, monitoring for psychiatric sideeffects including agitation and aggression Pick clear target symptoms and track changes using ratingscales with multiple informants. If no change in target symptoms, then discontinue themedication.
Cognitive Behaviour Therapy Gold standard psychosocial treatment of anxiety intypically developing children Increasing evidence of efficacy ofmodified CBT for higher-functioningchildren with ASDFor review see Compton et al. (2004)
CBT trials for anxiety in ASD Chalfant, Rapee et al. 2007 47 kids with anxiety disorder and high-functioning ASD Randomized to waitlist or group CBT modified Cool Kids program 71% remission of anxiety disorder in rx group vs. 0%waitlist group Reaven 2011: 47 children with high-functioning ASD and anxiety Randomized to CBT or “treatment as usual” (TAU) “Facing your Fears” (modified group CBT) 50% of CBT group showed improvement compared to9% of TAU group
CBT for ASD Wood 2009: Modified individual CBT for high-functioning children with ASDand anxiety N=40, randomized to active treatment vs. waitlist control 79% of CBT group showed improvement compared to 9% ofwaitlist group Treatment gains maintained at 3 month followup Sofronoff, Attwood 2005: N=71, 10-12 yr olds with Aspergers randomized to small group child CBT vs. child+parent CBT vs.waitlist Child+parent CBT more effective than child CBT
CBT vs. Recreational Tx Sung et al. 2011 N=70, ages 9-16, high-fxning ASD Randomized to 16 sessions small group CBT vs.small group social recreational therapy Both groups showed significant improvement inanxiety!
CBT studies ConclusionsGood emerging evidence for effectiveness of CBT in children withASD and anxiety Reductions in severity and number of anxiety diagnoses Some evidence of gains at follow-upParent involvement in treatment importantCaveats: Most studies had waitlist control groups, and effect sizes often dwindlewith active control groups All studies only looked at high-functioning ASD and didn’t include thosewith lower IQ All studies are with kids only, little information about adults
CBT Key Modifications1. Session structure2. Heavy parent involvement3. Make abstract concepts concrete4. Focus on behavioural manifestations of anxiety andbehavioural treatment strategies5. Cognitive restructuring – capitalize on black and whitethinking6. Multi-modal activities7. Generalization8. Reward programs9. Embed social skills training10. Integrate special interests
1. Key ModificationsSession structure Predictable Increased number of sessions High staff: child ratio Careful attention to pacing of activities
2. Key ModificationsHeavy parent involvement Participate in all sessions Opportunity to practice skills in parent-child pairs Parent support network Parent education Differentiate between adaptive vs. excessive protection Parent as coach
Parent TrainingExcessive Protection:Avoidance limits child’sexposure to anxietyprovoking situationsLimits child’sopportunity to gain skillsand practice effectivecoping strategiesAdaptive Protection:Careful considerationof skill levelParents titrate theirchild’s exposure tochallenging eventsCreate opportunities toexperience successthrough supportedpractice
3. Key ModificationsMake abstract concepts concrete Feelings Bodily sensations Thoughts Frequency and intensity of fears
4. Key ModificationsHeavy focus on behavioural manifestations ofanxiety and behavioural treatment strategies What does anxiety look like?• Use observable behaviour What can you do when worried?• Activities that are calming, relaxing• Deep breathing (e.g., bubbles, pin wheel, square breathing,bean bag on tummy)
5. Key ModificationsCognitive restructuring - capitalize on black-andwhite,rule-based thinking patterns Fight back with facts Provide a list of helpful thoughts, positive self-talk Rule/Plan: When I worry about…then I will… Use visual cues
6. Key ModificationsMulti-modal learning activities Hands-on Visually-based Multiple choice formats Provide examples, models
7. Key ModificationsGeneralization of concepts People Settings Activities Stimuli
8. Key ModificationsIntegrate reward programs Immediate & long-term rewards• Token economy• Prize box• Home-based reward program Reward brave behaviour, home-practice facing fears Reinforce group norms
9. Key ModificationsEmbed secondary treatment goals Social skills training• Group norms• Interacting directly with each other vs. through therapists Pre-requisite skills to face fears
10. Key ModificationsIntegrate special interests Individualized rewards Show-n-tell
II. Intellectual Disability With increasing cognitive impairment, emphasizebehavioural treatment strategies Functional analysis of behaviour Baseline? How and when does behaviour change? Situational triggers?
Consider skill deficits contributing to anxiety Communication - requesting basic needs, help, break Activities of daily living Need for predictability, routine Emphasis on contextual and contingencymodifications Escape/avoidance maintaining anxious behaviour? Need for consistent response to behaviour Use preventative strategies
Reward programs: Concrete Immediate or short-term Shaping desired behaviour
III. Adults with DD Consider how anxiety impedes Independent daily living skills Vocational skills Ensure rewards developmentally and ageappropriate Generalization of skills Importance of collaboration - with family, caregivers,residential, community living partners
Facing Your Fears - OverviewModified CBT group treatment for HFA/Asperger’s14 sessions (1.5 hours each)Max. 5 participants plus parent(s)3-4 group leadersGroup structure/routine: Large Group Parent-child pairs Individual parent and child groups Large GroupBooster session: 6 week follow-up
FYF: Weeks 1-7 Psycho-education Anxiety as “false alarm” Bodily symptoms as signals Externalize worry Creating “worry bugs” and “helper bugs” Identify situational triggers Identify worry thoughts or “active minds” Identify your “team”
FYF: Weeks 1-7 cont. Teach coping strategies Deep breathing Calming & relaxing activities Fighting back with facts Helpful thoughts Intro to exposure: facing fears a little at a timeAnalogy: Jumping into a cold swimming pool; Rollercoaster Identify rewards
FYF: Weeks 8-14 Identify treatment targets Develop fear hierarchies: “steps to success” In vivo practice At home practice Apply coping strategies Create “Face your Fear” videos
Parent training Psycho-education re.anxiety and CBT Identifying appropriatetreatment targets Discussion re. parentanxiety and impact onchild Metaphor of “parent ascoach” Heavy emphasis onparent involvement Identifying anxiety withinASD profile Finding the “Yellow Zone” Differentiating betweenadaptive and excessiveprotection Predicting and problemsolving
Other considerations Exclusion Criteria Not appropriate if OCD/ depression primary concern Severe ADHD Significant behavioural challenges Verbal IQ below 80 Parents unavailable to attend sessions Important Match participants based on cognitive abilities as muchas possible
ConclusionsAnxiety highly prevalent in individuals with DDGap in MH services for this populationRecognize unique presentation of anxiety in DD anddiagnostic challengesModified CBT treatments show promising evidenceDecrease severity and number of anxiety diagnosesA need for further research in application to ID and adultsImportant to tailor CBT to unique needs of individualswith DD
References Bellini, 2004 Chalfant, Rapee et al., 2007 Cochrane Review, 2010 Compton et al., 2004 Hollander, 2005 McDougle, 1996; 1998;2000 Reaven, 2011 Reaven et al., 2011 Russell & Sofronoff, 2005 Shulamite & Ben-Sasson, 2010 Simonoff et al., 2008 Skokauskas & Gallagher, 2011SOFIA STAART, 2009 Sofronoff & Attwood, 2005 Sung et al., 2011 Tantum, 2000 Thompson et al., 2011 Wood, 2009