Intensive cognitive-behavioural treatment for specific phobia in children and adolescents

The one session treatment approach (Ost, 1989) incorporates cognitive behavioural techniques into a single 3-hour intensive session. This treatment approach has led the field in the development of more efficient and intensive approaches for treating childhood anxiety problems, and for childhood specific phobia is now considered a 'well established' treatment (Ollendick & Davis III, 2012). This review examines the clinical phenomenology of specific phobia in youth, provides a brief description of OST along with the evidence to support its efficacy, and provides suggestions for future research.7 page(s

Intensive cognitive behavioural treatment for obsessive compulsive disorder in children and adolescents

Preliminary evidence for the efficacy of intensive treatments for childhood OCD is promising. This is an important area of research as traditional weekly CBT for OCD is costly, time intensive and is often challenging for families to access. This review explores the evidence base for intensive treatments for childhood OCD and following this, provides a description of a novel intensive treatment approach that combines prolonged intensive ERP sessions, similar to the one-session treatment for specific phobia, with CBT delivered over the computer via webcam (W-CBT) for one-month maintenance. Future research directions are also discussed.7 page(s

Comorbidity and treatment response in pediatric obsessive-compulsive disorder : a pilot study of group cognitive-behavioral treatment

This pilot study evaluated the effectiveness of group cognitive-behavioral treatment (CBT) on treatment outcomes for children and adolescents who presented with obsessive–compulsive disorder (OCD) and complex comorbid conditions, including depression, attention deficit/hyperactivity disorder and pervasive developmental disorders (PDD). Specifically, the impact of comorbidity on treatment response rates and remission rates was examined. Forty-three youth (aged 7–17) with OCD participated in group family-based CBT. Assessments were conducted at pre- and post-treatment and 6 months. Eighty-six percent of youth presented with a secondary psychiatric disorder, and 74% presented with a tertiary psychiatric condition. Contrary to the expected, comorbidity was not associated with poorer treatment outcomes at post-assessment. At longer term follow-up (6 months), however, treatment outcomes were poorer for youth with multiple comorbid conditions and for those with attention deficit/hyperactivity disorder. The finding that group CBT is largely effective for youth with comorbid conditions is of clinical and practical significance. Group delivery of CBT provides an efficient and cost-effective approach, and alleviates strain on services and service providers. Continued efforts are needed to improve long-term outcomes for youth with multiple comorbid conditions and attention deficit/hyperactivity disorder. Examining treatment response as a function of comorbidity with larger clinical samples is important to extend this research.9 page(s

Phobic anxiety

Children typically experience a range of fears during the course of their development. The content of these fears follows a predictable course that coincides with increasing cognitive development (Gullone, 2000; Muris et al., 2000; Ollendick et al., 2004), from concrete fears in infancy and toddlerhood (e.g. strangers and animals) to increasingly more abstract fears in childhood (e.g. ghosts, the supernatural) and adolescence (e.g. social fears, agoraphobia). Specific fears tend to peak in early childhood between the ages of 7 and 9 years and then begin to decline in children 10 years and older (Muris et al., 2000). While typically transient in nature, for some children fears persist and become more frequent, intensive and durable in nature, eventually evolving into a phobia (Ollendick et al., 2004). Phenomenology and epidemiology According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR; American Psychiatric Association, 2000) a specific phobia is an intense and persistent fear cued by the presence or anticipation of a specific object or situation. Exposure to the phobic stimulus typically provokes an immediate anxiety response or panic attack in the child and the phobic stimulus is typically avoided or, if avoidance is not possible, endured with considerable distress. Moreover, avoidance of the phobic stimulus generally interferes significantly with the child’s academic, social and family functioning. The fear cannot be better accounted for by another mental disorder. The DSM–IV–TR criteria take into consideration the tenets of developmental psychopathology and specify that fear should not be transient and must be present for at least 6 months in children. Additionally, unlike adults, children are not required to recognise that their fear is excessive or unreasonable.20 page(s

Treatment of aggressive obsessions in childhood obsessive-compulsive disorder

In this chapter, we discuss aggressive obsessions, which are obsessions related to violence or harm towards the self or others. Aggressive obsessions are highly distressing and prevalent, with reports of 30 to 70 % of youth obsessive-compulsive disorder (OCD) sufferers experiencing these symptoms. We outline the phenomenology and background literature on aggressive obsessions and then describe the case of a 16-year-old male experiencing aggressive obsessions. Case conceptualization, assessment, and treatment using cognitive behavioural therapy with exposure and response prevention are presented, followed by a discussion of complicating factors, conclusions, and key practice points.21 page(s

Specific phobia

Specific phobias are highly prevalent, affecting 5–10 % of children and adolescents in community samples and 15 % in mental health settings. Phobic youth experience significant interference and distress in their day-to-day lives and are at an increased risk of academic and social difficulties as well as adult psychopathology. Phobias have a complex etiology, developing from a multiplicity of factors including genetics, learning history, parenting, and evolutionary preparedness. This chapter reviews empirically supported assessment and treatment interventions for phobic youth. Strong empirical support currently exists for cognitive and behavioral treatments. In particular, the chapter focuses on the one-session treatment (OST) approach, which incorporates cognitive behavioral techniques into an intensive (3-h) treatment package. OST is a cost-effective and rapid treatment for phobic youth, with four randomized trials in four different countries now supporting its use. A case report illustrating the implementation of this treatment is presented.16 page(s

Responsibility beliefs, memory confidence, intolerance of uncertainty and the urge to check in childhood obsessive-compulsive disorder : an examination of cognitive theory

Objective: This study aimed to extend current research into cognitive models of obsessive–compulsive disorder (OCD) in a pediatric sample by examining the impact of perceived responsibility on memory confidence, intolerance of uncertainty (IU) and checking urge using an experimental design to manipulate perceived responsibility. It was hypothesised that the high responsibility condition would result in higher ratings of responsibility, lower memory confidence and higher IU, which would also result in higher ratings on urge to check. Moreover, it was hypothesised that adolescents would report significantly higher ratings of responsibility than children. Finally, it was hypothesised that the effect of perceived inflated responsibility on the urge to check in a high responsibility condition would be mediated by IU. Method: Twenty-seven children and adolescents diagnosed with OCD completed an experimental cognitive appraisal task (CAT) in which they heard two standardised vignettes presented in counterbalanced order; one in which participants were responsible and one in which they were not responsible for preventing harm to a friend's pet cat. Memory confidence, IU and checking urge were assessed after each scenario using Likert scales. Results: The manipulation of perceived responsibility was successful with children and adolescents rating increased responsibility in the high compared with the low responsibility scenario. There were no differences across high and low responsibility conditions, however, in ratings of memory confidence, IU or the urge to check. There were no significant age-related differences; however, there was a trend for adolescents to report higher ratings across all variables. Finally, the relationship between perceived inflated responsibility and the urge to check was not mediated by IU. Conclusions: Responsibility is not related to ratings of memory confidence, IU or the urge to check in a pediatric sample, suggesting that biases of responsibility may not be central to the formulation of childhood OCD. Results are discussed in terms of implications for cognitive formulations and cognitive approaches to treatment in pediatric OCD.15 page(s

Prognostic indicators of treatment response for children with anxiety disorders

Anxiety disorders are the most common mental health problems in youth, affecting 8–27 % of youth (Costello, Egger, & Angold, 2005). These disorders represent serious mental health problems for children and adolescents and lead to daily distress and impairment, peer and social relation problems (Chansky & Kendall, 1997; Langley, Bergman, McCracken, & Piacentini, 2004; Piacentini, Peris, Bergman, Chang, & Jaffer, 2007; Strauss, Forehand, Smith, & Frame, 1986), and significant difficulties in academic achievement (Kessler, Foster, Saunders, & Stand, 1995; King & Ollendick, 1989). Additionally, anxious youth often have poor self-esteem, more physical problems, and greater family conflict and distress than their peers (Ezpeleta, Keeler, Alaatin, Costello, & Angold, 2001; Harter, Conway, & Merikangas, 2003; Strauss, Frame, & Forehand, 1987). If untreated, childhood anxiety disorders tend to be chronic and unremitting in their course (Aschenbrand, Kendall, Webb, Safford, & Flannery-Schroeder, 2003; Keller, et al., 1992; Pine, Cohen, Gurley, Brooks, & Ma, 1998) and predict the development of other psychopathology later in life (Last, Perrin, Herson, & Kazdin, 1996; Woodward & Fergusson, 2001) including depression (Brady & Kendall, 1992; Cole et al., 1998; Pine et al., 1998; Seligman & Ollendick, 1998), externalizing disorders, and substance use disorders (Bittner et al., 2007, Costello et al., 2003, Last et al., 1996).19 page(s

Augmenting one-session treatment of children's specific phobias with attention training to positive stimuli

This study examined the efficacy of combining two promising approaches to treating children's specific phobias, namely attention training and one 3-h session of exposure therapy (‘one-session treatment’, OST). Attention training towards positive stimuli (ATP) and OST (ATP+OST) was expected to have more positive effects on implicit and explicit cognitive mechanisms and clinical outcome measures than an attention training control (ATC) condition plus OST (ATC+OST). Thirty-seven children (6–17 years) with a specific phobia were randomly assigned to ATP+OST or ATC+OST. In ATP+OST, children completed 160 trials of attention training responding to a probe that always followed the happy face in happy-angry face pairs. In ATC+OST, the probe appeared equally often after angry and happy faces. In the same session, children completed OST targeting their phobic situation/object. Clinical outcomes included clinician, parent and child report measures. Cognitive outcomes were assessed in terms of change in attention bias to happy and angry faces and in danger and coping expectancies. Assessments were completed before and after treatment and three-months later. Compared to ATC+OST, the ATP+OST condition produced (a) significantly greater reductions in children's danger expectancies about their feared situations/object during the OST and at three-month follow-up, and (b) significantly improved attention bias towards positive stimuli at post-treatment, which in turn, predicted a lower level of clinician-rated phobia diagnostic severity three-months after treatment. There were no significant differences between ATP+OST and ATC+OST conditions in clinician, parent, or child-rated clinical outcomes. Training children with phobias to focus on positive stimuli is effective in increasing attention towards positive stimuli and reducing danger expectancy biases. Studies with larger sample sizes and a stronger ‘dose’ of ATP prior to the OST may reveal promising outcomes on clinical measures for training attention towards positive stimuli.13 page(s