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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [245]-[249]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [245]-[249]
anxiety prevention programs implemented thus far, but methods to prevent such unintended consequences should be carefully considered.
Postvention, Follow-up, Dissemination (Monitoring Dissemination)
The studies conducted thus far have involved acute treatment and, at least in some studies, follow-up assessment only. It is unknown how to encourage ongoing use of skills learned in the prevention programs, nor is it known how best to encourage participation in follow-up assessments. Because the primary dependent variable of interest in prevention programs must be measured years later than the intervention was conducted, it is imperative to develop methods that encourage cooperation with long-term follow-up. Because most prevention interventions will likely be conducted in the school context, active collaboration with school administration will be critical to promote collection of these data. Families may also be able to facilitate participation, thus direct contact with families may be advisable. However, this raises issues with respect to confidentiality and the need to discuss up front with the young participant what will and will not be shared with parents and/or guardians. The preliminary success of the FRIENDS program in the hands of teachers bodes well for transportability of this program to treatment providers other than mental health professionals with expertise in CBT. Clearly the implementation of CBT-oriented prevention programs cannot realistically be limited to Ph.D.-level psychologists, and a multidisciplinary approach may be the best way to proceed. This raises interesting questions about the best way of disseminating CBT and the degree of expert supervision needed in the short and long run to optimize treatment delivery; these questions touch on cost-effectiveness of prevention programs. Research on the treatment of adult PTSD suggests that masters-level counselors can be trained to successfully deliver prolonged exposure for women who have been sexually assaulted; indeed, these counselors were as effective in delivering prolonged exposure as were CBT experts (Foa et al., 2002). However, the counselors received weekly supervision from CBT experts,
which increased the cost of the program. The next research question being currently examined is whether reduction in the amount of expert supervision for the counselors will reduce their success. A similar line of research needs to be pursued in adolescent anxiety disorder prevention, since the broad application of such interventions appears to be dependent on successful training of school personnel to implement these programs in the school context.
Impediments to Prevention
The first set of impediments to developing successful prevention intervention is the lack of knowledge about the complex interrelations among the various risk and protective factors for the development of anxiety disorders. Much is known about some specific factors but little is known about how they interact, which leaves the field bereft of a strong theoretical foundation upon which to build prevention programs. This may be the reason why prevention research has languished relative to treatment research: the factors associated with etiology may not be the same as those associated with maintenance, and thus comprehensive knowledge about the latter will allow for the development of treatment interventions even in the relative absence of the former. Practical considerations have stunted the development of prevention programs as well. Prevention efforts are likely to be costly, as they necessarily involve collection of data from large samples over a long period of time. Large samples are needed because of the relatively low base rates of anxiety disorder in the population of interest, and because there is insufficient information about who will actually go on to develop an anxiety disorder. Consequently, it is important to conduct broad screens to obtain sufficient numbers of vulnerable children and adolescents for inclusion in the studies. For example, most behaviorally inhibited infants do not develop an anxiety disorder later in life, and thus a large sample of inhibited children would be needed to detect the efficacy of a prevention program targeting behavioral inhibition. Further, because the relevant outcome is the future development
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of anxiety disorders and perhaps of subsequent comorbid conditions (e.g., depression, substance abuse), prevention studies require data collection for years after the intervention to determine its ultimate impact. The need to conduct longitudinal follow-ups of these large numbers for long periods of time renders the study of prevention programs impractical, especially when the primary funding sources for anxiety disorders research (e.g., National Institute of Mental Health)
typically favor shorter studies with more tangible impact. Thus, new sources of funding must be identified to generate knowledge that will inform the development of anxiety disorder prevention programs. Given the potential for anxiety disorders to derail adolescent development and thereby result in substantial personal and economic impact, these programs should be a major priority for a society that promises to leave no child behind.
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CHAPTER 12 Research Agenda for Anxiety Disorders
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Empirical work and theory over the past 25 years have illuminated many issues related to the concept of anxiety. First, investigators recognize that there are distinct temperamental vulnerabilities to various forms of anxiety and sets of symptoms in individuals. We have also learned that the neurochemistry of the limbic system probably makes a contribution to some of these temperamental biases. Each bias renders certain individuals susceptible to distinct symptom profiles. For example, patients with social phobia can be distinguished from individuals with blood phobia because the former are vulnerable to a vasovagal reaction to the sight of blood and, as a result, often feel faint. By contrast, social phobics have a more labile sympathetic nervous system characterized by increases in heart rate and blood pressure rather than a sudden drop in blood pressure to their feared targets. Given the large number of possible neurochemical profiles it is likely that there are many different anxiety disorders, each characterized by a specific class of symptoms. Scientists have also learned that the history of experience contributes to a development of an anxiety disorder. Children growing up in economically disadvantaged homes with less educated parents are more vulnerable to certain anxiety disorders than are advantaged children. Further, independent of social class background, the experience of abuse, neglect, or trauma increases the risk of developing an anxiety disorder. However, the cultural setting to which the child and adolescent must adapt is a relevant factor. Adolescents living in large urban centers in America and Europe are more vulnerable to social anxiety than those living in rural areas or small towns where there are few unfamiliar people and settings and greater social support. Each period of development is marked by anxiety over different targets. The human infant is provoked to anxiety by encounters with strangers or separation from caretakers. Three-year-old children experience anxiety when they anticipate or actually implement actions that violate
family prohibitions. Six-to eight-year-old children are made anxious by failing at tasks that are valued by their family or peers and adolescents are anxious over rejection or isolation from peers, and identification with a person or group categorized by the individual as undesirable or impotent and following detection of inconsistency among their beliefs. Thus, adolescents do not experience more intense anxiety than younger children. The important point is that their state of anxiety is linked to very different events and thoughts.
Scientists have not yet learned in any detail the specific biology that characterizes the varied temperamental vulnerabilities. That is, it is likely that each of the anxiety disorders is characterized by a profile of measures that includes reactivity of the sympathetic and parasympathetic nervous systems, as well as the propensity to secrete corticotropin-releasing hormone, norepinephrine, dopamine, GABA, glutamate, or any one of the opioids after encountering a challenge or stress. The task is to determine the specific profile that characterizes each anxiety disorder. We do not yet know the childhood and adolescent experiences that either exacerbate or mute the risk of developing an anxiety disorder. There is some research to show that infants who are at risk for developing social anxiety are helped if their parents do not overprotect them during the first year of life. We also need to know whether success in school tasks or on peer value activities reduces the risk of anxiety disorder in individuals who are temperamentally vulnerable. We do not know whether there have been historical trends in the prevalence of each of the anxiety disorders over the past century or two. Nor do we know whether females are more vulnerable to anxiety than males because of a combination of biology and cultural values or personal experience and culture alone. The female in almost all mammalian species is more avoidant to unfamiliarity than the male, which suggests a biological basis for the sex ratio. How
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ever, most cultures are more accepting of avoidant symptoms and the experience of anxiety in girls and women than in boys and men. Finally, we need to know more about the contribution of the amygdala to the development of any one of the anxiety disorders. The popular view at the present time is that the amygdala is the seminal structure mediating the acquisition of anxiety and fear because it is prepared to be responsive to threat. However, the amygdala is also responsive to unfamiliar or unexpected events. Therefore, we need to learn whether the amygdala is responsive to the threat of harm over and above its responsivity to unfamiliar events. This research should have profound implications for theory, for if the amgydala is not biologically prepared to react to dangerous events, the current animal model for human anxiety will be subject to critique.
Research is needed in four broad areas. First, we must determine or discover the fundamental anxiety disorder categories. This will require gathering reliable data on each individual's temperament, current biology, and life history. Currently, the diagnostic categories are defined only by self-reported symptoms, and as a result, each category is heterogeneous with respect to its etiology. It will be necessary to add behavioral and biological variables to interview and questionnaire data to arrive at the more fundamental anxiety disorder categories. Second, we should determine whether adolescents with distinct symptoms (for example, a panic reaction) have a special vulnerability that renders them vulnerable to develop anxiety over a specific class of target. As noted earlier, adolescents with a low threshold for a vasovagal reaction may be vulnerable to develop blood phobia, whereas those with a labile sympathetic system may be vulnerable to develop social phobia. This research, which is so critical for theoretical progress, must include a variety of biological variables, including power profiles and the asymmetry of activation in the electroencephalogram, event-related potential waveforms to threaten
ing and unfamiliar events, functional magnetic resonance imaging and positron emission tomography scanning, measures of the cardiovascular system and hypothalamic–pituitary axis, and, in the future, the concentrations of varied neurochemicals in the central nervous system. Finally, we need research to determine the experiential contributions to the various anxiety disorders by gathering a large number of psychological and sociological variables on every patient. These could include social class, ethnicity, educational attainment, academic performance, and family and peer relations. In addition, preliminary data point to the influence of month of conception and body build. For example, several reports indicate that children who are conceived in early fall when the light is decreasing are at slightly higher risk for becoming shy than those who are conceived in other seasons of the year. Individuals with an ectomorphic body build are at higher risk for social anxiety than children who are mesomorphic. If investigators gathered such a core set of variables on all subjects, we would gain a richer insight into the more fundamental categories of anxiety disorder and the contribution of experience to these phenomena.
TREATMENT OF ADOLESCENTS WITH ANXIETY DISORDERS
We can be fairly confident that treatments that have been empirically supported with anxiety-disordered adults, when adjusted to be developmentally appropriate, also appear to be efficacious for youth with these disorders. Most of our knowledge, however, refers to the acute phase of treatment and less is known about long-term maintenance or relapse. Cognitive-behavioral therapies (CBT) that involve some form of exposure to feared situations, objects, or thoughts appear to be especially helpful. The medications that have been reported as effective for adults, most notably the SSRIs, are also being found superior to placebo in several anxiety disorders such as OCD and GAD. Thus, the studies conducted to date suggest that CBT, medication,
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doi:10.1093/9780195173642.003.0013
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