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Suneeta Monga · Diane Benoit Assessing and Treating Anxiety Disorders in Young Children The Taming Sneaky Fears Program Assessing and Treating Anxiety Disorders in Young Children Suneeta Monga Diane Benoit (cid:129) Assessing and Treating Anxiety Disorders in Young Children The Taming Sneaky Fears Program 123 Suneeta Monga Diane Benoit Department ofPsychiatry Department ofPsychiatry Hospital for SickChildren Hospital for SickChildren Toronto, ON,Canada Toronto, ON,Canada and and Department ofPsychiatry Department ofPsychiatry University of Toronto University of Toronto Toronto, ON,Canada Toronto, ON,Canada ISBN978-3-030-04938-6 ISBN978-3-030-04939-3 (eBook) https://doi.org/10.1007/978-3-030-04939-3 LibraryofCongressControlNumber:2018962395 ©SpringerNatureSwitzerlandAG2018 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpart of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission orinformationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdeveloped. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexemptfrom therelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authorsortheeditorsgiveawarranty,expressorimplied,withrespecttothematerialcontainedhereinor for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictionalclaimsinpublishedmapsandinstitutionalaffiliations. ThisSpringerimprintispublishedbytheregisteredcompanySpringerNatureSwitzerlandAG Theregisteredcompanyaddressis:Gewerbestrasse11,6330Cham,Switzerland Acknowledgements WethankthePsychiatryEndowmentFundattheHospitalforSickChildrenforthe early seed funding nearly two decades ago to develop the Taming Sneaky Fears program and for their financial support for the ongoing refinement of the Taming SneakyFearsprogram.WearegratefultotheOntarioMentalHealthFoundationfor funding research activities that provided the empirical evidence documenting the efficacy of the Taming Sneaky Fears program. We also thank clinicians from various community mental health agencies in Northern Ontario, Canada, with a special mention of clinicians from Algoma Family Services in Sault Ste. Marie, Ontario, who have gained an expertise in implementing the Taming Sneaky Fears programand provided us with insights on how toeffectivelyteach this programto various professionals. We are also grateful to colleagues, trainees, parents, and childrenwhohaveparticipatedintheTamingSneakyFearsprogramattheHospital forSickChildren,Toronto,overtheyearsforalloftheirinvaluablefeedbackonthe various iterations of the program. v Contents 1 Anxiety Disorders in Young Children. . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Anxiety Versus Anxiety Disorder. . . . . . . . . . . . . . . . . . . . . . 1 1.2 Classification and Phenomenology . . . . . . . . . . . . . . . . . . . . . 2 1.3 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.4.1 Comorbidity Between Anxiety Disorders . . . . . . . . . . 7 1.4.2 Comorbidity Between Anxiety Disorders and Non-anxiety Disorders . . . . . . . . . . . . . . . . . . . . 7 1.4.3 Comorbidity Between Selective Mutism and Social Anxiety Disorder . . . . . . . . . . . . . . . . . . . 8 1.5 Etiological Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.1 Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.2 Behavioral Inhibition . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.3 Parenting Styles and Parental Anxiety . . . . . . . . . . . . 10 1.5.4 Additional Risk Factors Associated with Selective Mutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6 Impact on Family Functioning . . . . . . . . . . . . . . . . . . . . . . . . 11 1.7 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2 Screening and Assessment Tools for Young Anxious Children . . . . 17 2.1 Anxiety-Specific Screening Tools for Four- to Seven-Year- Old Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2.1.1 Preschool Anxiety Scale . . . . . . . . . . . . . . . . . . . . . . 17 2.1.2 Picture Anxiety Test. . . . . . . . . . . . . . . . . . . . . . . . . 19 2.2 Questionnaires Specific to Selective Mutism. . . . . . . . . . . . . . 20 2.2.1 Selective Mutism Questionnaire. . . . . . . . . . . . . . . . . 20 2.2.2 School Speech Questionnaire. . . . . . . . . . . . . . . . . . . 23 2.3 Diagnostic Assessment Tools for Young Anxious Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 vii viii Contents 2.3.1 Anxiety Disorders Interview Schedule for DSM-IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.3.2 Preschool Age Psychiatric Assessment. . . . . . . . . . . . 25 2.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3 Innovative Assessment Approaches for Young Anxious Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.1 Anxiety-Specific Screening Tools for Four- to Seven-Year- Old Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.1.1 Preschool Screen for Child Anxiety Related Emotional Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.2 Tools to Assess Selective Mutism and Social Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 3.2.1 Mutism Accommodation Scale . . . . . . . . . . . . . . . . . 31 3.2.2 Talking Behavior Assessment Tool . . . . . . . . . . . . . . 32 3.2.3 Selective Mutism Versus Social Anxiety Disorder Criteria Checklist . . . . . . . . . . . . . . . . . . . . 33 3.2.4 Steps to Talking. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3.3 Future Directions and Goals . . . . . . . . . . . . . . . . . . . . . . . . . 37 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 4 Current Evidence-Based Management . . . . . . . . . . . . . . . . . . . . . . 47 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4.2 Parent-Child Interaction Therapy . . . . . . . . . . . . . . . . . . . . . . 48 4.2.1 Bravery-Directed Interaction . . . . . . . . . . . . . . . . . . . 48 4.2.2 Coaching Approach Behavior and Leading by Modeling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.3 Cognitive Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.3.1 Parent-Child Dyadic Approach . . . . . . . . . . . . . . . . . 52 4.3.2 Child Group Approaches. . . . . . . . . . . . . . . . . . . . . . 53 4.4 Management of Selective Mutism . . . . . . . . . . . . . . . . . . . . . 56 4.4.1 Defocused Communication . . . . . . . . . . . . . . . . . . . . 56 4.4.2 Integrated Behavior Therapy for Selective Mutism . . . . 58 4.5 Summary of Interventions for Young Anxious Children . . . . . 59 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 5 The Taming Sneaky Fears Program: Development and Refinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 5.1 Creation of the Taming Sneaky Fears Program and Historical Context. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 5.1.1 Development of the Child Component. . . . . . . . . . . . 63 5.1.2 Development of the Parent Component . . . . . . . . . . . 65 5.1.3 Combining Child and Parent Components . . . . . . . . . 65 Contents ix 5.2 Research on the Taming Sneaky Fears Program . . . . . . . . . . . 66 5.2.1 First Feasibility Study. . . . . . . . . . . . . . . . . . . . . . . . 66 5.2.2 Pilot Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 5.2.3 Comparative Study . . . . . . . . . . . . . . . . . . . . . . . . . . 69 5.2.4 Selective Mutism and Social Anxiety Disorder Feasibility Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 5.2.5 Current Randomized Control Trial. . . . . . . . . . . . . . . 73 5.2.6 Quality Improvement Study . . . . . . . . . . . . . . . . . . . 75 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 6 The Taming Sneaky Fears Program: Theoretical Framework, Requirements for Implementation, and Program Overview . . . . . . 79 6.1 Theoretical Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 6.1.1 Adapting Traditional CBT for Young Children. . . . . . 80 6.2 Requirements for Implementation. . . . . . . . . . . . . . . . . . . . . . 83 6.2.1 Who Is a Good Candidate for Participation? . . . . . . . 84 6.2.2 Who Is Qualified to Implement the Taming Sneaky Fears Program?. . . . . . . . . . . . . . . . . . . . . . . 86 6.2.3 Where Can the Taming Sneaky Fears Program Be Implemented? . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 6.2.4 When to Implement the Taming Sneaky Fears Program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 6.3 Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 6.3.1 Duration and Frequency . . . . . . . . . . . . . . . . . . . . . . 88 6.3.2 Therapists-to-Parents and Therapists-to-Children Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 6.3.3 Setting and Materials . . . . . . . . . . . . . . . . . . . . . . . . 89 6.3.4 Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 7 The Taming Sneaky Fears Program: Introduction Session. . . . . . . 101 7.1 Purpose of the Introduction Session . . . . . . . . . . . . . . . . . . . . 101 7.2 Step-by-Step Guidelines to Implement the Introduction Session. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 7.2.1 Days or Weeks Prior to the Introduction Session . . . . 101 7.2.2 On the Day of the Introduction Session . . . . . . . . . . . 102 7.2.3 Introduction Session—Part A (Child Group Therapist Led) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 7.2.4 Introduction Session—Part B (Parent Group Therapist Led) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 x Contents 8 The Taming Sneaky Fears Program: How to Be a Feeling Catcher and the Boss of My Body . . . . . . . . . . . . . . . . . . . . . . . . . 113 8.1 Overview and Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 8.2 Step-by-Step Guidelines to Implement Part 1 of Session 1. . . . 114 8.2.1 For All Parent and Child Group Therapists . . . . . . . . 114 8.3 Step-by-Step Guidelines to Implement P-Session 1 . . . . . . . . . 117 8.3.1 Part One of P-Session 1 . . . . . . . . . . . . . . . . . . . . . . 117 8.3.2 Part Two of P-Session 1 . . . . . . . . . . . . . . . . . . . . . . 117 8.3.3 Part Three of P-Session 1 . . . . . . . . . . . . . . . . . . . . . 117 8.3.4 Part Four of P-Session 1. . . . . . . . . . . . . . . . . . . . . . 118 8.3.5 Part Five of P-Session 1 . . . . . . . . . . . . . . . . . . . . . . 126 8.4 Step-by-Step Guidelines to Implement C-Session 1. . . . . . . . . 127 8.4.1 Part One of C-Session 1 . . . . . . . . . . . . . . . . . . . . . . 127 8.4.2 Part Two of C-Session 1. . . . . . . . . . . . . . . . . . . . . . 127 8.4.3 Part Three of C-Session 1. . . . . . . . . . . . . . . . . . . . . 128 8.4.4 Part Four of C-Session 1. . . . . . . . . . . . . . . . . . . . . . 129 8.4.5 Part Five of C-Session 1. . . . . . . . . . . . . . . . . . . . . . 133 8.4.6 Part Six of C-Session 1. . . . . . . . . . . . . . . . . . . . . . . 134 8.4.7 Part Seven of C-Session 1. . . . . . . . . . . . . . . . . . . . . 135 8.5 Step-by-Step Guidelines to Implement C-Session 2. . . . . . . . . 135 8.5.1 Part One of C-Session 2 . . . . . . . . . . . . . . . . . . . . . . 136 8.5.2 Part Two of C-Session 2. . . . . . . . . . . . . . . . . . . . . . 137 8.5.3 Part Three of C-Session 2. . . . . . . . . . . . . . . . . . . . . 137 8.5.4 Part Four of C-Session 2. . . . . . . . . . . . . . . . . . . . . . 140 8.5.5 Part Five of C-Session 2. . . . . . . . . . . . . . . . . . . . . . 141 8.5.6 Part Six of C-Session 2. . . . . . . . . . . . . . . . . . . . . . . 141 8.6 Step-by-Step Guidelines to Implement C-Session 5. . . . . . . . . 142 8.6.1 Part One of C-Session 5 . . . . . . . . . . . . . . . . . . . . . . 142 8.6.2 Part Two of C-Session 5. . . . . . . . . . . . . . . . . . . . . . 143 8.6.3 Part Three of C-Session 5. . . . . . . . . . . . . . . . . . . . . 144 8.6.4 Part Four of C-Session 5. . . . . . . . . . . . . . . . . . . . . . 145 8.6.5 Part Five of C-Session 5. . . . . . . . . . . . . . . . . . . . . . 146 8.6.6 Part Six of C-Session 5. . . . . . . . . . . . . . . . . . . . . . . 146 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 9 The TamingSneaky Fears Program: Howto Be a Trick Catcher and the Boss of My Brain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 9.1 Overview and Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 9.2 Step-by-Step Guidelines to Implement P-Session 2 . . . . . . . . . 147 9.2.1 Part One of P-Session 2 . . . . . . . . . . . . . . . . . . . . . . 148 9.2.2 Part Two of P-Session 2 . . . . . . . . . . . . . . . . . . . . . . 149 9.2.3 Part Three of P-Session 2 . . . . . . . . . . . . . . . . . . . . . 149 9.2.4 Part Four of P-Session 2. . . . . . . . . . . . . . . . . . . . . . 155 Contents xi 9.3 Step-by-Step Guidelines to Implement C-Session 3. . . . . . . . . 155 9.3.1 Part One of C-Session 3 . . . . . . . . . . . . . . . . . . . . . . 156 9.3.2 Part Two of C-Session 3. . . . . . . . . . . . . . . . . . . . . . 157 9.3.3 Part Three of C-Session 3. . . . . . . . . . . . . . . . . . . . . 158 9.3.4 Part Four of C-Session 3. . . . . . . . . . . . . . . . . . . . . . 159 9.3.5 Part Five of C-Session 3. . . . . . . . . . . . . . . . . . . . . . 160 9.3.6 Part Six of C-Session 3. . . . . . . . . . . . . . . . . . . . . . . 160 9.4 Step-by-Step Guidelines to Implement C-Session 4. . . . . . . . . 161 9.4.1 Part One of C-Session 4 . . . . . . . . . . . . . . . . . . . . . . 162 9.4.2 Part Two of C-Session 4. . . . . . . . . . . . . . . . . . . . . . 162 9.4.3 Part Three of C-Session 4. . . . . . . . . . . . . . . . . . . . . 163 9.4.4 Part Four of C-Session 4. . . . . . . . . . . . . . . . . . . . . . 164 9.4.5 Part Five of C-Session 4. . . . . . . . . . . . . . . . . . . . . . 165 9.4.6 Part Six of C-Session 4. . . . . . . . . . . . . . . . . . . . . . . 165 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 10 The Taming Sneaky Fears Program: How to Climb Bravery Ladders and How to Manage Excessive Worries . . . . . . . . . . . . . . 167 10.1 Overview and Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 10.2 Step-by-Step Guidelines to Implement P-Session 3 . . . . . . . . . 167 10.2.1 Part One of P-Session 3 . . . . . . . . . . . . . . . . . . . . . . 168 10.2.2 Part Two of P-Session 3 . . . . . . . . . . . . . . . . . . . . . . 169 10.2.3 Part Three of P-Session 3 . . . . . . . . . . . . . . . . . . . . . 170 10.2.4 Part Four of P-Session 3. . . . . . . . . . . . . . . . . . . . . . 173 10.3 Step-by-Step Guidelines to Implement C-Session 6. . . . . . . . . 174 10.3.1 Part One of C-Session 6 . . . . . . . . . . . . . . . . . . . . . . 175 10.3.2 Part Two of C-Session 6. . . . . . . . . . . . . . . . . . . . . . 175 10.3.3 Part Three of C-Session 6. . . . . . . . . . . . . . . . . . . . . 176 10.3.4 Part Four of C-Session 6. . . . . . . . . . . . . . . . . . . . . . 179 10.3.5 Part Five of C-Session 6. . . . . . . . . . . . . . . . . . . . . . 180 10.3.6 Part Six of C-Session 6. . . . . . . . . . . . . . . . . . . . . . . 180 10.4 Step-by-Step Guidelines to Implement C-Session 7. . . . . . . . . 181 10.4.1 Part One of C-Session 7 . . . . . . . . . . . . . . . . . . . . . . 181 10.4.2 Part Two of C-Session 7. . . . . . . . . . . . . . . . . . . . . . 182 10.4.3 Part Three of C-Session 7. . . . . . . . . . . . . . . . . . . . . 182 10.4.4 Part Four of C-Session 7. . . . . . . . . . . . . . . . . . . . . . 183 10.4.5 Part Five of C-Session 7. . . . . . . . . . . . . . . . . . . . . . 184 10.4.6 Part Six of C-Session 7. . . . . . . . . . . . . . . . . . . . . . . 184 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 11 The Taming Sneaky Fears Program: The Pivotal Role of Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 11.1 Overview and Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 11.2 Step-by-Step Guidelines to Implement the Parent Feedback Meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

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