by Joye C. Anestis
"Are you on fire, from the years? What would you give for your kid fears?"
- Kid Fears, The Indigo Girls
In April, I wrote an article describing one-session treatment (OST) for specific phobias. OST is a massed cognitive-behavioral intervention which is empirically supported for the treatment of a variety of specific phobias. Most of the research on this treatment has been done with adult samples, but what about children? Can OST be effectively used to treat children with specific phobias? Research that existed prior to the Zlomke & Davis (2008) article I wrote about earlier was equivocal, but a new, more methodologically sound randomized controlled trial (RCT) has found that OST is an efficacious treatment in children.
First a bit about specific phobias and their treatment in children...after all, isn't it normal for kids to be scared of things? Of course! It is absolutely developmentally appropriate for children to have a wide variety of fears (e.g., the dark, the boogeyman, dogs, thunderstorms), and most children grow out of these fears and/or the fears don't get in the way of their ability to function in their world (e.g., they still have friends, they still sleep regularly at night, they still do well in school). For some children though (prevalence estimates range from 5-10%; Kessler et al., 2005), these phobias really hamper their lives and cause all sorts of difficulties (e.g., academic problems, interference in day-to-day activities, significant personal distress). Furthermore, childhood phobias significantly predict the presence of phobias in adulthood, and adult mood and anxiety disorders are frequently preceded by childhood specific phobias (Gregory et al., 2007). So treatment of these problems is imperative for kids' well-being, as well as for the possible prevention of later problems.
Several treatments are considered to be empirically-supported for specific phobias in children (see John Weisz's Psychotherapy for Children and Adolescents: Evidence-Based Treatments and Case Examples for an excellent treatment manual of all of these treatments), all of which are cognitive-behavioral in nature (specifically,in vivo exposure). For example, participant modeling combines modeling and in vivo exposure. Initially, a model (e.g., parent, therapist, peer) demonstrates fearlessness and coping while facing the child's feared stimuli. Then, using accepted exposure practices, the child is assisted in gradually interacting the feared stimuli him/herself. In reinforced practice, standard in vivo exposure is conducted and the child is rewarded (e.g., praise, toys, candy) for approaching and confronting the feared stimuli.
So back to the new study on OST conducted by Thomas Ollendick and colleagues - it compared OST with an education support condition and a waitlist control condition. Children and adolescents were recruited at two different sites, one in Sweden and one in southeast Virginia. Participants had to be 7-16 years old, with a specific phobia meeting DSM-IV-TR criteria that caused them significant impairment. They had to agree to discontinue other kinds of psychotherapy or any antianxiety medication. Individuals were excluded if they had any of the following: primary major depression, a pervasive developmental disorder, drug or alcohol abuse, or psychotic symptoms. 101 kids (62% girls) entered the Swedish sample, 70% of which had animal phobias and 44% of which had at least one comorbid mental illness. 95 kids (45% female) entered the Virginia sample. The majority of this sample (60%) had situational, natural environment, or "other" specific phobias (the most common was the dark or being alone). 94.7% of these kids had at least one comorbid mental illness. Random assignment was done within each site, but overall 85 were assigned to OST, 70 to education support, and 41 to the waitlist.
OST was conducted according the principles of Ost (1989, 1997) with adjustments made to the developmental level of each child. The maximum length of the treatment was 3 hours. OST consisted of graduated in vivo exposure in the form of behavioral experiments. These experiments allowed the children to draw new conclusions about the feared stimuli. The educational support treatment also lasted up to 3 hours and was based on the manual by Silverman et al. (1999). The child was given a workbook full of child-appropriate psychoeducation about fears, phobias, and anxiety. They were encouraged to keep the workbook at home and review it when necessary. No exposure or cognitive restructuring was done. Those placed on the waitlist were re-randomized to one of the treatment conditions after 4 weeks.
The overall findings are supportive of OST as an intervention for childhood phobias (as usual, there were a lot of results reported, so see the original article for more detail). On a number of assessment instruments, the OST outperformed the education support treatment and the waitlist. For example, clinician severity ratings were significantly lower for the OST than the other 2 groups. A significantly greater number of children (55%) were diagnosis free 3 weeks post-treatment than the education support (23%) or waitlist (2%) groups. These gains were maintained at 6-month follow-up. OST was also superior to education support treatment and the waitlist on treatment satisfaction. Interestingly, no significant differences between the 3 groups were found on some measures, including self-report and parents report measures. As is always the case, this new study is imperfect and warrants replication with some improvement, but it does offer some support for the use of OST in children. It seems OST can be added to the pantheon of effective treatments of specific phobias in children. We'll write more about some of the other treatments at a later time. But for now, we know that, just like phobias in adults, kid fears can be quickly and efficiently treated.