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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [220]-[224]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [220]-[224]
one treatment approach (psychosocial, medication) may then seek another approach as a way to rectify the less-than-preferred previous outcomes. Again, more information is needed about prior treatment history and its effect on the evaluation of a current intervention, and there is a real need for studies of the preferred treatment for patients whose response to treatments are less than satisfactory. Insufficient research on adults and almost none on youth regarding the continuation and maintenance treatment phases for specific phobia have been carried out. In adults with anxiety disorders, it may be recommended that medications be continued for at least 12–18 months and, thereafter, if the person is judged to be stable, that the medications be reduced very slowly to avoid withdrawal side effects. It is conceivable that at least some children and adolescents will require treatment for years, consistent with findings from the adult literature. As in other psychiatric and medical illnesses, after achieving a therapeutic response it is important to continue the same treatment (CBT and/or medications) to prevent relapses. During these phases, depending on the youngster's clinical status, she or he may need to be seen less frequently. It is important that an adequate trial be conducted (dose and duration of an SSRI; expertise and number of sessions of CBT) prior to concluding that a patient is a partial responder. For example, the Expert Consensus Guidelines for OCD recommend clomipramine after two or three failed SSRI trials (March, Frances, et al., 1997). Cognitive-behavioral therapy would be a first choice for an augmentation strategy after a partial response or nonresponse to adequate pharmacotherapy with an agent of known efficacy, although availability of trained therapists is sometimes limited, and some children are not motivated to participate. Systematic study of CBT dissemination strategies is sorely needed, as is the development of CBT techniques designed specifically to enhance motivation to engage fully in treatment. Such study is well under way in adult anxiety disorders, and clearly needs to be addressed next in children and adolescents. Much more needs to be done to establish the efficacy and safety of such augmentation for adolescents with anxiety disorders. Clinically we know that many are treated with this strategy, but the literature supporting this approach has yet to be developed.
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CHAPTER 11 Prevention of Anxiety Disorders
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THEORETICAL AND CONCEPTUAL MODELS OF PREVENTION AND CHANGE
The case for efforts in preventing anxiety disorder in youth has been made elsewhere (e.g., Weissberg, Kumpfer, & Seligman, 2003), but warrants brief reiteration here: (1) anxiety disorders are common (Kessler, 1994); (2) pediatric onset is also common (March, 1995); (3) anxiety disorders are associated with significant morbidity and comorbidity that often extends into adulthood (Costello & Angold, 1995); (4) the economic burden of anxiety disorders in the United States is enormous ($42.3 billion in 1990; Greenberg et al., 1999); and (5) most pediatric suf-ferers do not receive adequate care (Kendall & Southam-Gerow, 1995). Prevention efforts should target both risk and protective factors associated with the etiology and maintenance of the disorders. Some risk and protective factors may be less modifiable than others (e.g., gender, familial factors), and thus the interventions need to target mediating variables. The issue of timing is also important to consider because certain risk and protective factors may be more likely to exert their influence during certain developmental periods relative to other periods. For example, it may be when an adolescent needs to make the transition from middle to high school that being behaviorally inhibited (described in Chapter 9 and briefly below) heightens the adolescent's risk for developing an anxiety disorder. Consequently, the development of effective prevention of anxiety disorders will require (1) comprehensive knowledge of the risk and protective factors as well as their complex interrelationships during different periods in development; (2) advances in methods to detect the presence and/or absence of these factors; and (3) interventions that increase protective factors and/or reduce risk factors, or both. The goal of such programs is to reduce the enormous individual and societal burdens imposed by anxiety disorders. In reviewing the studies on prevention of anxiety disorder conducted to date with children and adolescents, we used the system advocated
by the Institute of Medicine's Committee on Prevention of Mental Disorders (Mrazek & Haggerty, 1994; Munoz, Mrazek, & Haggerty, 1996) and adopted by several prevention experts (e.g., Craske & Zucker, 2001; Donovan & Spence, 2000; Winett, 1998a). According to this system, prevention programs are classified as (1) indicated prevention programs, which target at-risk individuals who already have symptoms and/or a biological marker but do not fully meet diagnostic criteria for the disorder; (2) selective prevention programs, which target individuals presumed to be at high risk for the development of a disorder (e.g., witnesses of violence); and (3) universal prevention programs, in which entire populations are targeted regardless of risk factors (e.g., third graders). Before considering the intervention studies, it is important to briefly consider what is known about risk and protective factors at the individual, familial, and societal level, because it is knowledge of these factors and their interrelations that should inform the development of specific intervention strategies. Unfortunately, knowledge of such factors is limited, and perhaps the paucity of prevention studies in anxiety disorders is a direct result of this limited knowledge. Of particular concern is the absence of evidence about protective factors that are specific to anxiety disorders. That is, although the youth resilience literature has generally underscored the importance of factors such as high IQ, self-esteem, social support, and positive coping in serving to protect young people from the development of psychopathology in general, there is a paucity of literature regarding whether any protective factor(s) may serve to protect against anxiety disorders in particular. Certainly, development of effective prevention programs will continue to be hampered until evidence-based knowledge has accumulated in this area. The summary below is thus reflective of this in proportion to the literature; that is, considerable more coverage is paid to risk factors than to protective factors.
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INDIVIDUAL RISK AND PROTECTIVE FACTORS
Individual Psychological Characteristics
Elevated but Subsyndromal Anxiety Symptoms
Many children exhibit symptoms of anxiety at some time before adulthood, and two questions are of particular interest here: (1) Do children with elevated but subsyndromal levels of anxiety show greater than normal levels of impaired functioning in their roles at home, at school, or with peers? (2) Does subsyndromal anxiety predict later psychiatric disorder, whether an anxiety disorder or some other diagnosis? To answer both questions it is necessary to control for comorbidity with other symptoms and disorders; that is, impaired functioning or future anxiety disorder must be linked directly to the anxiety symptoms, not to other symptoms or disorders that may co-occur. To address the question of whether adolescents with elevated but subsyndromal levels of anxiety show greater than normal levels of impaired functioning in their roles at home, at school, or with peers, it is helpful to draw upon data from the Great Smoky Mountains Study of youth aged 9 to 16 (Costello, Mustillo, Erkanli, Keeler, & Angold, 2004). In this study, in which 1,420 children and adolescents and their parents were interviewed annually, children and adolescents with an anxiety disorder but no other psychiatric diagnoses were twice as likely to show functional impairment as those with no disorder. Even among youths with no diagnoses, those with symptoms of anxiety were twice as likely to have impaired functioning compared to those with no symptoms. This was true of both pre-and postpubertal youths. Thus, in this population-based sample, subsyndromal anxiety symptoms were associated with youths' impaired ability to function well at home, at school, and with peers. Regarding whether subsyndromal anxiety predict later psychiatric disorder, data from the same study were used to compare children and adolescents who had an anxiety disorder at least once in the 8-year period of observation with those who had never had an anxiety disorder.
Youths who had an anxiety disorder at least once during that period had an average of two symptoms during the years when they did not have a diagnosis; the average for those who never had an anxiety disorder was 0.4 symptoms. This finding suggests that youths with a vulnerability to anxiety disorders show clinical symptoms even at times when they would not meet formal diagnostic criteria. Among children and adolescents without a history of anxiety disorders, those who developed one disorder in any given year of the study had three times as many subsyndromal anxiety symptoms in the year before they developed a disorder compared to those who did not develop an anxiety disorder (2.0 vs. 0.7 symptoms). Almost half of the youths who developed a new anxiety disorder the following year had at least two clinically significant symptoms the previous year, compared with one in five youths who would not develop a disorder. This finding suggests that it should be possible to identify high-risk children and adolescents for prevention programs with a high degree of accuracy. It is important to remember, however, that anxiety disorders are not all that common among children and adolescents. In the Great Smoky Mountains Study, although subsyndromal symptoms quadrupled the likelihood that a youth without a previous history of anxiety disorders would develop one, the likelihood was increased from 1% to 4% only. It follows that 96% of the children and adolescents with two or more anxiety symptoms did not develop a disorder within the next year. Overall, children and adolescents with the highest likelihood of an anxiety disorder were those with a past history of anxiety disorders (13%).
Although research findings are consistent in showing that children and adolescents who display anxiety display alterations in autonomic reactivity, Sweeny and Pine ( 2004) have noted limits in studies that have relied on cardiovascular measures as indices of autonomic activity. These limits include the fact that cardiovascular measures are regulated by a wide variety of neural structures and thus provide relatively indirect
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information about the state of brain systems that might be implicated in anxiety disorders. In addition, abnormalities in cardiovascular control appear to occur in other conditions, and so they do not appear to be specific to anxiety disorders. The context in which cardiovascular measures are obtained can also influence any reactivity that might be observed on these measures, thereby raising a concern about whether such findings are actually epiphenomena (Sweeny & Pine, 2004). Respiratory indexes, in contrast, are relatively free of the limits noted above with cardiovascular measures (Sweeny & Pine, 2004). Respiratory indexes that have been used in this area of research include minute ventilation (the amount of air breathed every minute), tidal volume (size of each breath), and respiratory rate. Guided by Klein's ( 1993) theory that panic attacks are a suffocation alarm triggered by cues of suffocation, most of the research using respiratory indexes has focused on using samples of patients with panic disorder or an anxiety disorder other than panic disorder as well as “normal” controls and have had the participants breathe air that has an increased concentration of carbon dioxide. Although research findings generally show that patients with panic disorder experience high degrees of anxiety, panic attacks, and changes in respiratory parameters in response to carbon dioxide exposure whereas other patient groups and normal controls do not (e.g., Papp et al., 1993; Papp, Martinez, Klein, Coplan, & Gorman, 1995), these findings have not emerged in all studies (e.g., Rapee, Brown, Antony, & Barlow, 1992; Woods & Charney, 1998). Only one study (Pine, Cohen, Gurley, Brook, & Ma, 1998) has extended this work to young people (ages 7 to 17; mixed sample of anxiety disorders), but separate analyses were not conducted for the preadolescent versus adolescent subsamples. Pine et al.'s findings with this sample of youth paralleled the positive findings obtained with adults. In light of the paucity of research conducted with adolescent samples, considerable more research is needed before firm conclusions can be drawn about the influence of adolescents' autonomic reactivity as a risk factor for anxiety disorders.
The detailed review of the temperamental vulnerability to behavioral inhibition was also presented earlier. It is currently known from two independent labs that children who were highly reactive to novel stimuli as infants were more likely than others to display extreme shyness, timidity, and restraint to unfamiliar people, situations, and objects when they were 2, 4, 7, and 11 years of age (Fox, Henderson, Rabin, Caikins, & Schmidt, 2001; Kagan, 2002), and were more likely to show biological differences that may implicate the amygdala. Although these children are at 3-to 4-fold increased risk for development of an anxiety disorder compared to other children, most do not go on to develop one. Thus, behavioral inhibition is not a strong predictor of later anxiety disorder. This finding points to the importance of identifying protective factors that limit the rate of later anxiety disorders in vulnerable individuals.
There are several characteristics of the individual that have been linked with anxiety and its disorders in children and adolescents. In Chapter 9, mention was made of information-processing biases and anxiety sensitivity. In this section, two additional cognitive characteristics are indicated: coping skills and perceived control. Individuals' coping skills strategies, which refer to a variety of methods individuals employ in an attempt to cope with negative or aversive situations, may be categorized as (1) problem-focused, (2) avoidant, or (3) emotion-focused. Problem-focused coping refers to strategies that either directly address or minimize the effect of the problem. Avoidant coping focuses on either avoiding or escaping the problem. Emotion-focused coping is directed toward the subjective level of distress associated with the problem. There is research evidence that problem-focused methods such as actively seeking out information, positive self-talk, diversion of attention, relaxation, and thought-stopping are associated with reduced levels of anxiety and emotional distress in 8-to 18-year-olds (Brown, O'Keefe, Sanders, &
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doi:10.1093/9780195173642.003.0012
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