Investigation and Treatment of Worry and Generalised Anxiety Disorder in Children.

445 Pages·2017·2.21 MB·English

No Worries - It's Just Not That Easy!: Investigation and
Treatment of Worry and Generalised Anxiety Disorder in
Children
Author
Holmes, Monique Colette
Published
2014
Thesis Type
Thesis (PhD Doctorate)
School
School of Applied Psychology
DOI
https://doi.org/10.25904/1912/1798
Copyright Statement
The author owns the copyright in this thesis, unless stated otherwise.
Downloaded from
http://hdl.handle.net/10072/367586
Griffith Research Online
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No Worries – It’s just not that easy!
Investigation and Treatment of Worry and Generalised
Anxiety Disorder in Children.

Monique Colette Holmes
Bachelor of Psychological Science (Honours)
Bachelor of Criminology and Criminal Justice

School of Applied Psychology
Griffith Health
Griffith University

Submitted in fulfilment of the requirements of the degree of
Doctor of Philosophy (in Clinical Psychology)

April, 2014
Worry and Generalised Anxiety Disorder in Children ii
Worry and Generalised Anxiety Disorder in Children iii
ABSTRACT
Generalised Anxiety Disorder (GAD) is a highly prevalent, chronic and costly
mental disorder in children, that is characterised by excessive and uncontrollable worry
about numerous topics, that occurs more days than not for a period of at least six
months (APA, 2013). Our knowledge and understanding of worry and GAD in children
remains a neglected area of empirical enquiry. Given the dearth of research conducted
with children in this area, much of what is currently known about childhood GAD is
derived from empirical studies conducted with adults. Within the adult literature,
research has demonstrated that cognitive factors such as intolerance of uncertainty (IU),
positive and negative beliefs about worry (PBW and NBW), negative problem
orientation (NPO) and cognitive avoidance (CA) are particularly important in the
development and maintenance of pathological worry and GAD, and these variables
therefore constitute the basis of treatment for adult GAD. Treatment programs for child
GAD, unlike those for adults, are almost uniformly transdiagnostic in nature and do not
specifically target the cognitive variables demonstrated to be involved in the aetiology
and maintenance of the disorder.
This thesis investigated the cognitive variables of IU, NBW, PBW, NPO, and
CA with respect to worry and GAD in children through a series of four studies, which
have all been submitted for publication. The first study examined the cognitive variables
of IU, NBW, PBW, NPO, and CA in a community sample of 114 children, aged 8 to 12
years. It was found that all child cognitive variables were significantly and positively
related to child worry, and that parent worry, IU and CA were significantly and
positively related to child worry. It was also found that the relationship between parent
IU, NPO and CA and child worry was mediated by child IU, NPO and CA respectively.
The second study examined whether levels of IU, NBW, PBW, NPO and CA
differed between children diagnosed with GAD (n=25) and non-anxious children
Worry and Generalised Anxiety Disorder in Children iv
(n=25). It also examined whether levels of IU, NBW, PBW, NPO and CA differed
between parents of children diagnosed with GAD (n=25) and parents of children
without an anxiety disorder (n=25). Overall, with the exception of PBW, children with
GAD endorsed significantly higher levels of worry, IU, NBW, NPO and CA compared
to non-anxious children. Parents of children with GAD were not found to differ from
parents of non-anxious children on worry or any of the five cognitive variables.
Based on the results of Study 1 and 2, the third study described the development
of a disorder-specific treatment program for child GAD (the “No Worries! program”)
that aimed to target the cognitive variables and symptoms associated with GAD. It
provided a detailed discussion of the strategies taught to children and highlighted some
of the challenges involved. A case study was presented to demonstrate the feasibility of
achieving successful outcomes with a complex presentation.
The final study provided a preliminary examination of the efficacy of the No
Worries! program through a randomised controlled trial (RCT). Forty-two children with
a primary diagnosis of GAD, aged between seven and 12 years, and their parents, were
randomly assigned to either a treatment (TX) or waitlist (WLC) condition. At post-
treatment, 52.9% of children in the TX group compared to 0% of children in the WLC
group were free of their primary GAD diagnosis. At post-treatment, compared to the
WLC children, TX children demonstrated a greater reduction in clinical severity, greater
improvement in overall functioning, and held fewer clinical diagnoses. By 3-month
follow-up, 100% of children in the TX group were free of their GAD diagnosis and
50% were free of all diagnoses, and all other gains made at post-treatment were either
maintained or enhanced at this time point.
In summary, this thesis makes an important and valuable contribution to our
growing knowledge base regarding the development and maintenance of excessive
worry and GAD in young children. Together, the studies provide preliminary evidence
Worry and Generalised Anxiety Disorder in Children v
that the cognitive factors present in adult models of worry are applicable to children,
especially children with GAD, and that a disorder-specific treatment program for
children with GAD is effective in treating this chronic and disabling disorder.
Worry and Generalised Anxiety Disorder in Children vi
STATEMENT OF ORIGINALITY
This work has not previously been submitted for a degree or diploma in any
university. To the best of my knowledge and belief, the thesis contains no material
previously published or written by another person except where due reference is made
in the thesis itself.
……………………………..
Monique Colette Holmes
Date: 2nd April, 2014
Worry and Generalised Anxiety Disorder in Children vii
TABLE OF CONTENTS
Abstract…………………………………………………………………………………....... iii
Statement of Originality…………………………………………………………………….. vi
Table of Contents…………………………………………………………………………… vii
List of Tables …………………………………………………………………………......... xii
List of Figures ….……………………………………………………………………….….. xiv
List of Abbreviations…………………………………………………………………….…. xv
List of Publications……………………………………………………………………….… xvii
Acknowledgements………………………………………………………………………..... xix
Preamble……………………………………………………………………………………... 1
SECTION 1 – LITERATURE REVIEW
Chapter 1 – Anxiety Disorders in Childhood……………………………………………... 5
Description of DSM-5 Anxiety Disorders…………………………………………… 8
Social Anxiety Disorder ...…………………………………………………... 9
Separation Anxiety Disorder………………………………………………… 9
Specific Phobia………………………………………………………………. 10
Generalised Anxiety Disorder……………………………………………...... 10
Panic Disorder …………………………………………................................. 11
Agoraphobia………………………………………………………………..... 11
Obsessive-Compulsive Disorder…………………………………………….. 11
Posttraumatic Stress Disorder………………………………………………... 12
Epidemiology…...………………………………………………………………….... 15
Risk Factors for Childhood Anxiety……………………………………………….... 18
Summary……………………………………………………………………………... 22
Treatment of Childhood Anxiety…………………………………………………..... 22
Transdiagnostic CBT Programs……………………………………………… 23
Disorder-specific Treatments………………………………………………… 28
Chapter Summary…………………………………………………………………..... 30
Chapter 2 – Generalised Anxiety Disorder……………………………………………...... 31
Normal versus Pathological Worry………………………………………………...... 33
History of Generalised Anxiety Disorder…………………………………………..... 34
DSM-III……………………………………………………………………… 35
DSM-III-R…………………………………………………………………… 36
DSM-IV & DSM-IV-TR…………………………………………………...... 36
DSM-5……………………………………………………………………...... 37
Models of Generalised Anxiety Disorder…………………………………………..... 39
Borkovec’s Avoidance Theory of Worry…………………………………..... 39
Mennin’s Emotion Dysregulation Model……………………………………. 40
Wells’ Meta-Cognitive Model of Worry……………..…………………….... 40
Dugas’ Cognitive Model of Worry and GAD…..………………………….... 42
Summary……………………………………………………………………... 44
Cognitive factors associated with GAD in adults…………………………………..... 45
Worry and Generalised Anxiety Disorder in Children viii
Intolerance of Uncertainty…………………………………………………… 45
Positive and Negative Beliefs about Worry………………………………...... 47
Negative Problem Orientation……………………………………………….. 49
Cognitive Avoidance………………………………………………………… 53
Summary……………………………………………………………………………... 55
Treatment of GAD in adults………………………………………………………..... 55
Chapter Summary……………………………………………………………………. 58
Chapter 3 – Generalised Anxiety Disorder in Children...……………………………....... 61
Worry in Children……………………………………………………………………. 63
Epidemiology of GAD in Children………………………………………………….. 65
Aetiology of GAD in children……………………………………………………….. 69
Cognitive factors associated with GAD in children………………………………..... 71
Intolerance of Uncertainty…………………………………………………… 72
Positive and Negative Beliefs about Worry…………………………….......... 73
Negative Problem Orientation……………………………………………….. 75
Cognitive Avoidance………………………………………………………… 76
Summary…………………………………………………………………….. 77
Treatment of GAD in Children……………………………………………………..... 77
Chapter Summary…………………………………………………………………..... 80
SECTION 2 – A SERIES OF RESEARCH STUDIES
Preamble……………………………………………………………………………………... 83
Chapter 4 (Study 1) - Investigation of the cognitive components of worry in a
community sample of young children aged 8 to 12 years………………………………… 89
Abstract………………………………………………………………………..…….. 90
Intolerance of Uncertainty………………………………………………….... 92
Beliefs about Worry………………………………………………………...... 93
Negative Problem Orientation……………………………………………...... 94
Cognitive Avoidance……………………………………………………….... 95
The Current Study…………………………………………………………………..... 96
Method……………………………………………………………………………….. 98
Participants………………………………………………………………....... 98
Measures – Children……………………………………………………......... 98
Measures – Parents…………………………………………………………... 101
Procedure…………………………………………………………………………….. 103
Results……………………………………………………………………………….. 104
Data Analytic Procedures……………………………………………………. 104
Screening Analyses…………………………………………………………... 105
Preliminary Analyses………………………………………………………… 106
The relationship between child cognitive variables and child worry……....... 106
The relationship between parent variables and child variables……………… 106
Mediation of parent worry and child worry by child cognitive variables…… 107
Mediation of the relationship between parent cognitive variables and child
worry by child cognitive variables………………………………………….. 108
Worry and Generalised Anxiety Disorder in Children ix
Discussion………………………………………………………………………........ 108
Strengths and limitations and suggestions for future research…………………......... 112
References………………………………………………………………………........ 114
Tables and Figures………………………………………………………………….. 123
Chapter 5 (Study 2) - Understanding the cognitive components of worry in children
with Generalised Anxiety Disorder aged 7 to 12 years…………………..………………. 137
Abstract……………………………………………………………………………... 138
Highlights…………………………………………………………………………… 139
Method…………………………………………………………………………........ 146
Participants………………………………………………………………..... 146
Procedure……………………………………………………………………. 147
Diagnostic Status……………………………………………………………. 148
Measures – Children………………………………………………………... 148
Measures – Parents………………………………………………………..... 150
Results……………………………………………………………………………..... 152
Discussion…………………………………………………………………………… 153
Strengths and Limitations…………………………………………………………… 156
Conclusions and Implications……………………………………………………..... 158
References…………………………………………………………………………… 159
Tables and Figures…………………………………………………………………... 166
Chapter 6 (Study 3) – A disorder-specific, cognitively-focused, group treatment for
childhood GAD: Development and case illustration of the No Worries! program…….. 173
Abstract……………………………………………………………………………… 174
Highlights…………………………………………………………………………… 175
The No Worries! Program………………………………………………………….. 181
Overview…………..................................................................................................... 182
Intolerance of Uncertainty………………………………………………….. 183
Cognitive Avoidance………………………………………………………... 184
Negative Beliefs about Worry……………………………………………….. 186
Negative Problem Orientation……………………………………………….. 186
Perfectionism……………………………………………………………........ 187
Sleep Issues………………………………………………………………....... 189
Summary……………………………………………………………………... 190
Case Illustration…………………………………………………………………...... 190
Presenting Problem………………………………………………………..... 191
History of Presenting Problem and Previous Assistance……………………. 192
Measures…………………………………………………………………………..... 193
Results……………………………………………………………………………..... 196
Determination of Clinical Status and Clinical Reliable Change……………. 196
Pre-Treatment to Post-Treatment Assessment……………………………….. 196
Three-Month Follow-Up……………………………………………………. 198
Client Satisfaction……………………………………………………………. 199