BARLOW'S

 "TRIPLE VULNERABILITY MODEL"

FOR ANXIETY DISORDERS

• The development of anxiety and its disorders is a function of an interaction of three dispositions

1. Biological Vulnerabilities: heritable biological diathesis (genes, monozygotic concordance, high heritability for anxiety d/o
2. Generalized Psychological Vulnerability: sense of impending uncontrollable and unpredictable threat or danger (e.g.,history of lack of control may put individuals at risk for experiencing chronic  negative emotional states through the development)
3. Specific Psychological Vulnerability: early learning (vicarious learning) experiences that focus anxiety on certain circumstance, parents discussing events as threatening and dangerous and reinforcing avoidance or escape (e.g., physical sensations are dangerous; social evaluation is dangerous; bad thoughts are dangerous)

When all 3 interact and its precipitated by a stressful life event it may lead to the development of an anxiety d/o

Social Anxiety

ASSESSMENT

• Semi-structured Interview:
  • Anxiety Disorders Interview Schedule for DSM-IV (ADIS)
• Self-Report
  • Social Anxiety Scale for Children-Revised
  • Social Phobia and Anxiety Inventory for Children
• Self-monitoring
  • Write down situations causing nervous/sick feelings
  • rate intensity of nervous feelings
• Broadband rating scales
  • CBCL, TRF
• Physiological Evaluation
  • Heart rate, sweat indices
• Sociometric measurement
  • Soliciting peer ratings (nominations)
  • Determine level of popularity and social intx
• Direct observations of select times

Social Phobia

Risk Factors and Maintaining Variables

• Genetic
  • Greater risk in twin studies & relatives w/ d/o
• Family
  • overprotection, lack of parental warmth, disrupted attachment
  • Parents w/ anxiety, depression, or substance abuse d/o
  • Model perception of environmental threats from their parents
• Stressful life events
  • Social trauma
• Child characteristics
  • learned helplessness
  • social apprehension, feelings of uncontrollability, behavioral inhibition
• Relates to behavioral inhibition
  • effects 10-15% of kids
  • Temperament assctd w/ escape, avoidance, dependent, passive bx
• Reinforced by parental attention (praise, sympathy
• May try to escape undesired tasks

Social Phobia

Developmental Aspects

• Behavioral Inhibition has a stable course
• Not getting enoughsocial intx in the environment
• Learning specific play bxs lead to better outcome
• gender differences

• Skills deficit: doesn't have skills (teach skills

or

• Production deficit: has skills but does not produce it (train skills)

School Refusal

ASSESSMENT

• Semi structured interview: ADIS
• Evaluation of maintaining factors: School Refusal Assessment Scale (SRAS)
• Self-Report/parent/teacher ratings of severity of depression and anxiety: Visual Analogue Scale for Anxiety Revised (VAA-R)
• Assessment of family functioning: Family Environment Scale or the Family Assessment Measure
• Psychoeducational and language assessment
• Review of school attendance

• Previous studies has shown that 50% of kids have at least 1 more comorbidity diagnoses, either an additioanl specific phobia, SAD, ADHD, ODD, GAD
• This study compared 2 groups of kids w/ specific phobia (Natural enviroment type and animal type)
  • Youths w/ natural environment type specific phobia were more clinically impaiered and less satisfied w/ the quality of life eventhough both groups were equally severe and both rated similar dysfunctional beliefs about phobia
  • May be due to natural envirnoment type is more uncontrollable and animal type avoidance is possible

Anxiety Disorder

Learning Theory

Predisposition of being conditioned easier not predisposed for fear or anxiety

• Specific Phobia
  • Traumatic event leads to conditioned fears
  • Fears can also be learned through observation
  • diathesis-stress-model, genetically based vulnerability for phobias, personality factors affect speed and strength of conditioning, differences in life experiences
  • certain fears are more easily conditioned and more resistant to extinction b/c there is an evolutionary reason
• Social Phobia
  • traumatic conditioning
  • social learning
  • culturally transmitted norms
  • Evolutionary purposes can strengthen conditioning
  • temperatment plays a role in behavioral inhibition
  • Uncontrollability plays a role (learned helplessness)
• Panic Disorder w/ or w/o Agoraphobia
  • exteroceptive conditioning-conditioned stimuli impinge on sensory system
  • and interoceptive-fear of fear-body's internal sensation
  • Conditioning takes place for those that are vulnerable during the initial panic attack-interoceptive  (pounding heart) and exteroceptive (mall)
• PTSD
  • Uncontrollable and unpredictable stress-helplessness, increased avoidance bx, numbing, conditioned emotional responses to cues
  • Effects of prior experiences and genetic factors
• GAD
  • Emphasis on the role of uncontrollable and unpredictable aversive events, hx of childhood trauma
  • Suppression of emotion and physiological processess reinforces worry
  • worry is used as a cognitive avoidance bx of fear of anxiety
• OCD
  • Verbal transmissions of dangerous thoughts and social learning
  • Rituals are avoidant responses
  • evolutionary preparedness--contamination, danger

1. Symptom level: layperson's terms, subjective feeling of tension or fear
2. Syndrome or disorder: group of symptoms that cluster together
3. Nosological: specific syndrome that has certain time-course, prognosis, and tx response

Anxiety Disorders

ASSESSMENT

(GENERAL APPROACH)

• Semi-structured Interview: ADIS or Diagnostic Interview Schedule for Children Version IV
  • ADIS  gets the history of d/o, assesses other d/o, and allows clinician severity ratings
• Rating Scales: Revised Children's Manifest Anxiety Scale (RCMAS) for youth--most widely used; and CBCL for parents (TRF for teachers?)
  • RCMAS is a narrowband
  • RCMAS II gets to younger ages
  • Includes a Lie scale-useful to see if child is lying
• Direct Observations
  • behavioral avoidance
  • parent-youth interaction
  • most commonly used in fear situation or family intx
• Self-Monitoring
  • Its efficient and easy to id and qualify symptoms, controlling variables, and tx outcomes
  • Diaries usedto assess bx, thoughts, mood

Another anxiety d/o

Depression

Externalizing d/o

PTSD

ASSESSMENT

• Interview
• Rating Scale: Trauma Symptom Checklist for Children
• Anatomical dolls to assess sexually abused youths?

• Low family income, isolated family, marital conflict, parental substance abuse, presence of a step father, patriarchal attitudes, lack of social contact, sexually restrictive family attitudes
• Poor mother-child relationship
• Sexual preconditions for abuse
  • Perpetrator must be motivated to abuse child sexually
  • Perpetrator must overcome inhibitions regarding sexual activity w/ a child
  • Perpetrator must overcome external obstacles
  • Perpetrator must overcome child's resistance to sexual contact

• Avoiding thoughts about the trauma may exacerbate symptoms; must assimilate thoughts for the PTSD symptoms to abate
• Integrated mode
  • traumatic events, emotional, biological responses, attributions, individual characteristics, characteristics of social environment

• Children w/ more advanced cognitive development may appraise the event as more traumatic and be more susceptible to depression and fear--but they have greater coping skills
• Children react worse to traumatic events b/c they have less control, more disorganized behavior
• Young children are better at dissociating themselves fromthe event---may protect them from PTSD; may lead to dissociative identity d/o

PTSD

Prevalence

• 6-7% population exposed to stressors each year
• Large survey: 25% of children have experienced a highly traumatic event by age 16
• 6% had experienced this type of event in the past 3 mths
• 36% of children exposed to truamatic events are diagnosed w/ PTSD
• Children are at least as likely to be diagnosed as adults
• Average---incidence rates of PTSD symptoms among symptoms among traumatized children are above 20%
• 1/4-1/3 of those in traumatic event will develop PTSD
• The more intense, frequent, violent, the more likelihood of getting PTSD

PTSD

Developmental Course and Prognosis

• Symptoms peak w/i 1st year after traumatic experience, many have symptoms year later
• 10% will get symptoms after 6 mths of trauma
• 30% have symptoms that last less than 1 yr
• 16.4% willhave symptoms up to 1-2 yrs later
• 12.6% up 2-3 yrs later
• 14.4% up to3-5 yrs later
• 26.1% more than 5 yrs later

• Seeing blood during event
• Being Trapped
• Thinking they might not escape
• Feelings of panic and fear during disaster
• High anxiety 5 mths after disaster

PTSD

Model?

• Not everyone exposed to traumatic event will have PTSD
• The traumatic event-must have been exposed to a traumatic event
• The more chronic or ongoing the more stressful
• If event is perceived as uncontrollable or personal its more stressful
• 2 types of stressors
  1. acute, nonabusive
  2. chronic, abusive

Stress reactions can be moderated atany stage by characteristics of the individual and of the environment; biological vulnerability, psychological strengths and vulnerabilities, experiential vulnerability, gender differences, ethnic/cultural variations, developmental differences, coping behavior

PTSD

DIAGNOSIS

• Diagnose Acute Stress D/o when have symptoms up to a month
• Delayed onsite PTSD-6 months later
• Age 5-14 years
  • Developmentally limited to concrete aspects, less influenced by adaptation as you get older you have gist memories

1. Exposure to traumatic events
2. Preexisting child characteristics (gender, age, ethnicity)
3. Characteristics of the postdisaster recovery environment (major life events & social support)
4. coping skills (negative or positive coping

• Overall PTSD symptoms decline over time
• PTSD symptoms did not differ by grade or gender
• Overall results supported  the conceptual model for predicting children's reaction over the year following major natural disaster
• Each of the factor in the model was predictive of children's PTSD symptomatology
• Results show the importance of conducting early assessment of PTSD
• Children who have high levels of both life threat and loss/disruption in a disaster are likely to show lingering symptomatology
• Coping effors were higher among children w/ greater postdisaster distress
• Negative strategies (blaming self/others, yelling, anger) predicts PTSD symptoms over time