Today’s excellent workshop presented by Muniya Khanna Ph.D, began the FCP 2016 Fall Professional Workshop Series was entitled:“Cognitive Behavioral Treatment of Anxiety and OCD in Children and Adolescents: Beyond the Manual.”

Dr. Khanna had a pleasant and easygoing style. Her soft tone of voice required a microphone for all to hear her. In general, Dr. Khanna’s sense of humor, calm voice, obvious knowledge of her topic, and relevant “real-life” examples made the 3-hour presentation go very quickly. She also handled most questions very well. She gave good answers and did not let the questions interrupt the flow of her presentation.

Dr. Khanna’s goals for participants in this workshop included:

• Identify symptoms, risk factors, and maintaining factors of child anxiety and OCD.
• Describe the current empirical evidence on the treatment of child anxiety and OCD.
• Describe the CBT model of child anxiety and OCD.
• Identify intervention strategies that target key factors within the model, including exposure.
• Describe treatment strategies targeting parent factors related to the development and maintenance of child anxiety and OCD and to treatment outcome.

All goals were met. As described, the workshop provided an intermediate-level understanding of the cognitive-behavioral formulation of anxiety, the principles of the treatment components, and the techniques to implement them.

During her presentation, Dr. Khanna included 4 sections that were the framework to meet her goals for the Workshop. These were:

1. An overview of Anxiety and OCD in Children and youth, including Symptoms, Prevalence, course of treatment and assessment.
2. Principles of Cognitive-Behavioral Treatment for Anxious Youth, including a discussion of the model, and key components.
3. Intervention Components, including a discussion of CBT, and Exposure plus response prevention (EXRP).
4. Finally, Dr. Khanna addressed barriers to treatment including parent factors and common roadblocks.

Section 1 provided a description of Anxiety and OCD, with data to support the need for treatment and treatment efficacy for this disorder. Dr. Khanna said that anxiety can be described simply as thoughts or behaviors representing unrealistic fears that interfere with development, daily routine, and/or social relationships. She pointed out that the lifetime prevalence rate of anxiety in the US is 28% and that 13% or over 6 million children suffer from anxiety disorders in the US. A range of 0.5% to 3% of children worldwide suffer from Obsessive-Compulsive disorder (OCD). Anxiety disorders, including OCD lead too negative social and school impact, depression, suicidal ideation, substance abuse, and multiple risk factors for physical health. problems.

As Dr. Khanna described:

• Anxiety Disorder symptoms in children may differ slightly among the various types.
• Separation anxiety disorder is characterized by tremendous fear and worry being apart from home or a loved one after age 6.
• Social Anxiety disorder is a persistent fear of one or more social situation that may provoke panic attacks or somatic symptoms.
• Generalized Anxiety disorder is an excessive worry over day to day events.
• OCD is recurrent and persistent thoughts, impulses or images which are intrusive and cause marked anxiety or distress. The person attempts to suppress these with some other thought or action.

Dr. Khanna mentioned that most anxiety disorders have a comorbidity rate with another anxiety disorder of 30%.

The good news regarding anxiety disorders, as stated by Dr. Khanna is that Anxiety disorders are very treatable in children and youth. Dr. Khanna described some excellent assessment instruments, including the Yale-Brown OCD scale, and the Multidimensional Anxiety Scale. She said that while both psychotherapy and medication therapy are effective, the combination of medication and CBT has shown a success rate of 81%. She cautions that success is not universal and there is still much research to be done.

Section 2 was focused on a brief overview of Cognitive Behavioral Therapy (CBT). Dr. Khanna discussed the familiar triangle representing the CBT Theory of Emotion. Thoughts, interpretations or cognitions, along with learning history, and biology allow an emotional response that leads to a behavior. For example, a perception of a feared outcome (“They will think I’m stupid!”), may produce physiological symptoms (Poor concentration, heart racing, somatic issues), may lead to a behavior (Avoid or put-off an action.), to provide temporary relief but does not solve the anxiety problem. Dr. Khanna pointed out that the normal fight or flight response goes “haywire” in these situations, creating fear when no fear is necessary. Dr. Khanna made it clear that the person experiences anxiety, not by the situation, but by the person’s interpretation of the situation.  All anxiety is maintained by “avoidance”. The therapists job is to minimize anxiety and build competence and confidence in coping.

Section 3 focused on treatment and intervention components. Dr. Khanna discussed the “Coping Cat” technique treatment components including the importance of a relationship with the client and parents, providing clear identification of the somatic reactions, teaching relaxation, challenging noxious thoughts and teaching problem solving with use of rewards and gradual exposure to the anxiety stimulus.  CBT always includes psychoeducation so that the child and the parents have a better understand of the symptoms and treatment steps. CBT also always includes a “Cognitive Restructuring” component to reframe blame for symptoms from the child to a “battle” against anxiety by the child and the parents. The therapist will provide corrective information about anxiety, identify and challenge “Automatic Thoughts”, and develop rational responses to them.

Dr. Khanna also discussed the Exposure plus response prevention (EXRP) model for treatment OCD in children and youth.

EXRP is a CBT protocol that includes:

• Psychoeducation
• Cognitive Training
• Mapping OCD: Development of Treatment Hierarchy
• Exposure plus response prevention (EXRP)
• Relapse Prevention

In this model, the parents and the child always work together and “anxiety” is seen as the “bully” to be faced with increasing exposure to the OCD symptoms and triggers. Behavior is clearly defined and Rewards are used frequently for the child’s effort.  Dr. Khanna also described limitations to this model, including that it is time intensive, sensitive to family anxiety and comorbidity, uses unconventional components, and works best with medication management.

During section 4, Dr. Khanna addressed some potential barriers to treatment of anxiety in children and youth. She pointed out that about 80% of parents also meet the criteria for an anxiety disorder. These parents are less likely to engage in treatment with their child. They are also more likely to have negative thoughts and communicate anxious beliefs to the child. Dr. Khanna also said that parents with anxiety are less likely to participate in “home-work” exercises with their child. She suggested that the therapist take a step back by spending more time in relationship development with the anxious parent. This can be done by gently addressing the parent anxiety about beliefs and the treatment, modeling or allowing the parent to watch the exposure in the session, allowing for difficulty in home assignments and breaking the assignment into smaller steps that are easily accomplished.  Dr. Khanna emphasized that exposure for the child is very difficult for the anxious child. It is better to start with a low stimulus that is easily achieved by the child, and move slowly up the hierarchy to help the parent become comfortable with the treatment.

Overall, this was a winner! In her Workshop today, Dr. Khanna managed to pack 30+ years of research and practice on this topic into 3 very satisfying hours. I’m sure that she has the knowledge to spend many more hours presenting on this topic. The only negative comment was from several folks in the back of the auditorium stating that Dr. Khanna spoke too softly. This was resolved with the addition of a microphone. During the break, comments were positive and most participants appeared eager to return for the second half.

Any other thoughts?