How To Test The Effectiveness Of An Occupation Based Group For Children With Anxiety

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1 An occupation-based group for children with anxiety Ema Tokolahi, 1 Cheryl Em-Chhour, 2 Laura Barkwill 3 and Sarah Stanley 4 Research Key words: Children, anxiety, occupation, group intervention, outcome measures. Introduction: Anxiety significantly affects children in middle childhood, impacting on functioning and predicting future mental health problems. Despite this, there is little literature describing occupational therapy for this population. This preliminary study evaluated the acceptability and outcomes of an occupation-based group for children with anxiety aged years. Method: The group employed developmentally appropriate occupations to teach and participate in cognitive, behavioural and functional skills for managing anxiety. The five outcome measures used were the Beck Youth Inventories, Occupational Questionnaire, Child Behaviour Checklist, Health of the Nation Outcome Scales for Children and Adolescents, and Children s Global Assessment Scale. Acceptability was measured by attendance and outcome measures were taken at pre-group and post-group (n = 34). Data were examined using repeated measures t-tests. Results: All 34 participants completed the intervention, with 87.9% attendance. Parent-rated child anxiety decreased, as did clinician-rated factors inhibiting optimal functional performance, and clinician-rated overall child functioning increased. No significant changes in child-rated measures were reported. Conclusion: Preliminary findings were that the occupation-based group for children with anxiety aged years was an acceptable and beneficial intervention for reducing parent-rated and clinician-rated symptoms of anxiety while increasing functioning. 1 Occupational Therapy Practice Supervisor. 2 Occupational Therapist. 3 Clinical Psychologist. 4 Research Coordinator. 1-4 Auckland District Health Board, Kari Centre, Auckland, New Zealand. Corresponding author: Ema Tokolahi, Occupational Therapy Practice Supervisor, Kari Centre, Greenlane Clinical Centre, Private Bag 92189, Auckland, New Zealand. [email protected] Reference: Tokolahi E, Em-Chhour C, Barkwill L, Stanley S (2013) An occupation-based group for children with anxiety. British Journal of Occupational Therapy, 76(1), DOI: / X The College of Occupational Therapists Ltd. Submitted: 13 March Accepted: 10 August Introduction Experiencing a level of anxiety is normal and typically at its peak during the first years of a child s life (Silverman and Treffers 2001). It is reported that up to 10.5% of children aged years experience clinical anxiety, which produces unhelpful internal cognitions and impacts on their participation in occupations, level of functioning and development (Zhan-Waxler et al 2000, Costello et al 2003). Furthermore, a significant relationship between anxiety and depression has been clearly identified (Silverman and Treffers 2001, Costello et al 2003), with anxiety disorders in childhood and adolescence shown to precede and predict later depressive disorders (Merrick 1992, Zhan-Waxler et al 2000). Consequently, the need for early intervention is vital (Friedberg et al 2000). Cognitive behaviour therapy (CBT) is the most widely researched nonpharmacological intervention of anxiety in children and adolescents. CBT is reported to be highly effective in modifying an individual s internal cognitions; however, it has been found insufficient in producing significant change when level of functioning was measured as an outcome (Vitiello et al 2006). It seems logical that for change to be most effective, improvements in level of functioning need to occur alongside changes to internal cognitions to support positive mental health (Costello et al 2003). In this context, the effect of clinical anxiety on functioning refers to a child s level of occupational participation and occupational performance in developmentally appropriate occupations (Zhan-Waxler et al 2000, Costello British Journal of Occupational Therapy January (1) 31

2 An occupation-based group for children with anxiety et al 2003). One measure of occupational participation and functioning is time use: there is a complex relationship between activity, participation and conditions such as anxiety. Merrick (1992) found that when children are engaged in more activity, they display fewer maladaptive mood symptoms. Such imbalance of occupational participation creates an increased risk for wellbeing and the onset of mental illhealth (Krupa et al 2003). Although concern for the relationship between functioning and anxiety is well documented, evidence for interventions directly targeting functional impairment, rather than cognitive processing errors alone, was limited (Vitiello et al 2006). Occupational therapy is uniquely suited to providing interventions to effect change in level of occupational participation and functioning; however, there has been no systematic research to evaluate the effectiveness of occupational therapy as an intervention for anxiety in children and adolescents. There is a need for such research addressing the relationship between activity participation and mental illness, particularly in children (Krupa et al 2003). This preliminary study investigated an occupation-based group targeting functioning and internal cognitions for children with anxiety aged years. Intervention Context This study was conducted at a child and adolescent mental health service (CAMHS) in New Zealand. Access to this service requires a moderate to severe mental health difficulty defined by level of functional impairment reduced or impaired occupational functioning rather than diagnostic criteria alone. The need for an intervention targeting anxiety in the years age group was identified and an occupation-based group was developed in response. Development The intervention was developed in group format as a way to reduce costs while maintaining therapeutic benefit comparable to individual treatment (Wood et al 2001, Flannery-Schroeder et al 2005). Additionally, it was anticipated that the group context of the occupation-based intervention in this study would in itself be therapeutic. The group intervention was designed around theory about engagement, participation and performance of daily activities impacting on mental health from occupational therapy (Mandel et al 1999), modification of internal cognitions from CBT (Huebner 2007), orienting interventions towards a desired outcome rather than problem focused from solution-focused brief therapy (Furman 2004) and the clinical experience of the authors regarding groupwork processes and developmentally appropriate activities. A group manual outlining the session plans was developed by the authors, who took turns facilitating the group with each other (assisted by other clinicians from the CAMHS) to ensure a level of consistency (see Table 1 for an outline of each session s content). Table 1. Outline of session topics Session Session topic 1 Introductions and psychoeducation 2 Emotions and occupational participation 3 CBT five-part model and physical responses to occupational participation 4 Activity scheduling and graded occupational engagement 5 Anticipatory occupations and anxiety 6 Adventure activity experiential learning 7 Review own level of participation and impact of mental health 8 Managing anxiety in communication and social situations 9 Review and celebration Studies identified increased effectiveness of interventions when a parenting intervention was integrated (Silverman et al 1999). Alongside the children s group intervention ran a parallel parenting group providing parents with psychoeducation and peer support; however, it is beyond the scope of this article to report on the evaluation of this intervention. Intervention aims One aim of the children s group was to use developmentally appropriate occupations to teach and participate in cognitive, behavioural and functional skills for managing anxiety, such as activity scheduling and graded occupational engagement. Another aim was to reduce related impairments in functioning, such as school refusal or excessive participation in ritualistic occupations. Structure The children s group ran weekly for 1.5 hours, over 9 consecutive weeks. Because this was a new initiative, the group format evolved slightly over each series and intervention adherence was not formally evaluated. Each session followed a similar format: warm-up activity related to session topic, review of skills practice from previous week, use of activity to learn a new skill (see Table 2 for an example), relaxation, practice of new skill, planning skills practice for the coming week and a closing round. Table 2. Example of an occupation used to teach a new skill Occupation: Charades New skills: Format: Communication and self-awareness around the impact of emotions on occupational participation. Based on the traditional game of Charades, each participant takes turns to select two cards: an emotion and an occupation. Participants must act out the combination of the two cards in silence, while others in the group have to guess what they are trying to convey. Spontaneous comments often reflect on how it is easier to combine some pairs (for example, to act out happy while brushing my hair ) and more difficult to act out others (for example, doing homework while anxious ). During debrief, the participants are encouraged to consider how their own emotions might affect the way they participate in daily occupations and vice versa. 32 British Journal of Occupational Therapy January (1)

3 Ema Tokolahi, Cheryl Em-Chhour, Laura Barkwill and Sarah Stanley Fig. 1. Participant flow through study. Table 3. Demographic information for participants Variable Intervention n % Gender Male Female Age (years) Range Mean (SD) (1.06)... Ethnicity New Zealand European Maori Pacific Island Asian African Study design Aims This prospective study used a repeated measures design with no randomisation to evaluate: Acceptability of the intervention as measured by attendance Effect of the intervention on anxiety symptoms and level of functioning in children aged years. Participants Children were internally referred as clinically indicated, according to the following criteria: (a) aged years, (b) presented with anxiety symptoms, (c) able to converse in basic English, (d) engaged in treatment as usual, (e) not engaging in suicidal or parasuicidal behaviour and (f) not suspected of or diagnosed as experiencing psychotic phenomena. Practically and ethically, randomisation was not appropriate (see Fig. 1). The demographic and basic clinical characteristics of child participants are summarised in Table 3. Ethics Ethical approval for this study was granted by the Central Regional Ethics Committee (CEN/09/04/015) and relevant local institutional boards. Children and parents gave informed consent to participate in the study and understood their right to withdraw. Outcome measures The acceptability of the intervention was measured by the children s attendance over the 9 weeks. Five clinical outcome tools were used to measure the effect of the intervention: 1. Beck Youth Inventories (BYI), a checklist consisting of five inventories that the child rates to indicate his or her current internal emotional state. The Anxiety inventory was selected to measure child-rated symptoms of anxiety (Beck et al 2005). 2. Occupational Questionnaire (OQ), a time-use diary that categorises activities into self-care, leisure and productivity, with concurrent Likert scales for children to rate each activity s Primary diagnosis Adjustment with anxiety Anxiety Attention deficit hyperactivity disorder Asperger s Dyspraxia Parent-child relationship Post-traumatic stress disorder No diagnosis assigned importance and their perceived level of ability. It is used as a measure of occupational participation providing an indicator of child-rated functional level (Smith et al 1986). 3. Child Behaviour Checklist (CBCL), a checklist consisting of several scales rated by a child s parent to describe problematic behaviours. The Anxiety, Depression/Withdrawn, Aggression, Thought Problems and Internalisation subscales were selected to measure parent-rated symptoms of anxiety in their children (Achenbach 1991). 4. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), where a child s health and social functioning are scored on 13 clinical features covering four broad areas: behaviour, learning and physical impairment, psychological/emotional symptoms and social functioning. There are two additional questions measuring parent understanding of these factors. This tool was used to measure clinician-rated factors inhibiting optimal functional performance (Gowers et al 1999). 5. Children s Global Assessment Scale (CGAS), a numeric, criterion-referenced scale (1 to 100) used by clinicians to provide a rating for the general functioning of children over the previous week. It was used in this study to measure clinician-rated levels of functioning in the children (Schaffer et al 1983). Diagnostic interviews were not conducted as participants would previously have undergone a semi-structured interview on entry to the CAMHS that established evidence of Axis-I or comorbid anxiety. It was not within the scope of this project to accommodate the associated costs (financial and time) of repeating these interviews. British Journal of Occupational Therapy January (1) 33

4 An occupation-based group for children with anxiety Data collection Five intervention groups ran consecutively over a 14-month period, with six to eight children per group and a total of 34 participants (see Fig. 1 for participant flow through the study). Parent-rated and child-rated outcome measures were completed with one of the first three authors during the first and last intervention sessions. Follow-up data were collected at 3 months after group completion, but are not reported here as the sample size was too small (n = 6) and meaningful interpretations could not be drawn. Data analysis Descriptive data related to attendance were used to evaluate intervention acceptability. The results of pre-group and postgroup ratings from outcome measures (BYI, OQ, CBCL, HoNOSCA and CGAS) were compared, using repeated measures t-tests to assess for potentially significant differences. The significance level was set at 0.05 and analysis was conducted by SPSS 16.0 for Windows (SPSS Inc, Chicago, IL). Results Participants The participant demographics are given in Table 3. Attendance Ten of the participants referred did not enter the intervention group; the reasons given were ineligible, not ready to attend a group, moving out of the CAMHS catchment area, discharge and transportation/logistical barriers. All 34 participants who were allocated to a group completed the intervention (100%) and attended 87.9% of the sessions, with the average number of sessions missed per participant being 1.03 (ranging from 0 to 3). Clinical outcomes Comparison of the 34 participants ratings at pre-group, and again 9 weeks later at post-group, found a decrease in the means of parent-rated Anxiety and Internalising subscales on the CBCL to be statistically significant (p<0.001 and p<0.01 respectively), indicating a reduction in anxiety symptoms displayed by the children. There was a significant decrease in the mean clinician-rated HoNOSCA score (p<0.001), indicating reduced factors inhibiting optimal functional performance, and an increase in mean CGAS score (p<0.01), suggesting improvement in overall functioning. There were no statistically significant changes found on the other CBCL subscales, the child-rated BYI inventory, or OQ (see Table 4). Discussion Acceptability It was hoped that the occupational nature of the group would be acceptable to participants and that this could be gauged by attendance. The intervention group was not the Table 4. Psychometric values at pre-intervention and post-intervention Mean pre- Mean post- Change intervention intervention between mean score score pre-group and (Standard (Standard post-group deviation) deviation) scores Self-rated BYI Anxiety (13.6) (15.4) OQ Activities (3.1) (1.7) Competence (0.5) (0.5) Enjoyment (0.6) (0.6) Parent-rated CBCL Anxiety (14.0) (13.4) *.. Depression/withdrawn (11.1) (10.4) Aggression (10.2) (10.6) Thought problems (9.6) (8.8) Internalisation (12.6) (15.0) ** Clinician-rated CGAS ** HoNOSCA *.. *p<0.001, **p<0.01. BYI = Beck Youth Inventories; OQ = Occupational Questionnaire; CBCL = Child Behaviour Checklist; CGAS = Children s Global Assessment Scale; HoNOSCA = Health of the Nation Outcome Scales for Children and Adolescents. only intervention available to participants and they had the option to participate in alternative or concurrent treatments. Given the level of choice open to participants, this study s attrition rate of zero is exceptional, particularly considering Garfield s (1994) report that 25-50% of patients (across several studies) failed to return after an initial session. As with any intervention offered to children, it is unclear how much of their attendance was driven by their own or their parents motivation for them to engage in treatment. Anecdotal feedback from the participants suggested that the occupational nature of the group appealed to them and so it would appear to have supported attendance and acceptability. Intervention effect Reductions in anxiety symptoms and improved functional level were anticipated outcomes from pre-group to post-group. Interestingly, results showed a discrepancy between childreported outcomes and those of the parents and clinicians between pre-group and post-group measures. Several reasons are proposed to explain this phenomenon. First, it has been shown in other studies that change in observable behaviour takes effect quicker than change in internal cognitions (Vitiello et al 2006). So while participants parents and clinicians reported change in observable behaviours, there may have been a delay in cognitive changes becoming habituated (Csikszentmihalyi 1993). Secondly, the children s ratings at pre-group and postgroup indicate a possible floor effect not considered at the 34 British Journal of Occupational Therapy January (1)

5 Ema Tokolahi, Cheryl Em-Chhour, Laura Barkwill and Sarah Stanley study outset. Improvements reported by parents and clinicians suggest that the children may not have accurately reported symptoms at pre-group (perhaps due to lack of awareness or the effect of peer pressure), making the measured degree of change in their self-reported symptoms inaccurate. To minimise the impact of this potential factor, it is vital to have external (for example, clinician-rated) measures alongside the self-rated and parent-rated measures, as in the present study. Finally, it would be imprudent not to consider the possibility that no significant difference was found in selfratings because the group did not affect change in the measured variables. Given the changes reported in the parentrated and clinician-rated measures, this explanation seems unlikely. However, parents and clinicians were not masked to the child s participation in the intervention and their desire to see change may in itself have created a rater bias. Consequently, this study found that participation in the intervention was beneficial in reducing parent-rated symptoms of their child s anxiety and internalising problems and that occupational functioning, as rated by clinicians, was enhanced by reducing factors inhibiting optimal functional performance and increasing participation. Limitations The limitations of this study include lack of randomisation, no control or comparison group and a small sample size which mean that conclusions made can only be tentative and may not be generalisable and the use of attendance as an indirect measure of acceptability. In this study, parents and clinicians rated different constructs (anxiety and level of functioning, respectively) and in future studies it would be useful to have them rate the same constructs to improve triangulation. There were several difficulties associated with conducting this evaluation in a CAMHS. First, access to a larger sample was restricted and randomisation not feasible. Although follow-up data were collected, they were of insufficient quantity to elicit meaningful interpretations. Including a larger follow-up sample in future research would provide useful insights into the benefit and longevity (if any) of the intervention effects. Secondly, pre-group and post-group measures were collected within the intervention; however, completion of these in the presence of the clinicians facilitating the intervention and conducting this research may have elicited socially desirable responses, potentially creating rater bias. Furthermore, standardised diagnostic interviews were not routinely conducted within the CAMHS, therefore a large proportion of the participants (12 out of 34) had no formal diagnosis. Such interviews would have provided a more robust measure of the diagnostic status of participants at different time points. Children reported finding the OQ unwieldy and it took longer to complete than anticipated (often more than 20 minutes). Many of the questionnaires were returned incomplete or inaccurately filled out. The OQ was not developed specifically for use with children, although it has been used with young adolescents (12 years+) in other studies (Ebb et al 1989). Variation in interpretations of how to categorise occupations participated in was extensive and there were multiple, potentially conflicting, options for how to analyse data, resulting in a limited usable amount (Ebb et al 1989). A more suitable occupational therapy outcome measure for use with children, such as the Children s Occupational Self Assessment (Keller et al 2005) or the Children s Assessment of Participation and Enjoyment (King et al 2004), is recommended for future studies. Implications for occupational therapy This study represented an important opportunity to evaluate an occupation-based group. Positive outcomes of the intervention were found, suggesting that the occupational nature of the group was both acceptable and beneficial in reducing symptoms of anxiety and increasing level of functioning. Importantly, by intervening during childhood there is the potential that the benefits will mitigate more debilitating disorders in later life (Tomb and Hunter 2004). As such, the importance of early intervention should not be undervalued (Friedberg et al 2000). Evaluation of this occupation-based intervention for children with anxiety contributes to the limited pool of evidencebased interventions available to mental health professionals in CAMHS. While CBT is the most commonly researched intervention found to be effective for children with anxiety, there is a clear need for research supporting the practice of those who do not practise CBT and who can provide legitimate, alternative, cost-effective programmes that are beneficial for this population (Christiensen et al 2010). Findings from this study support the role of occupational therapists working with children in community mental health services and reflect the valuable contribution occupational therapy can make to their recovery. Acquiring occupational therapy specific knowledge in this area is important, not only with respect to the individual outcomes but also with respect to funding, service and professional development. Conclusion The aim of this study was to evaluate the acceptability of an occupation-based group for children with anxiety aged years and its effect on anxiety symptoms and level of functioning. Preliminary findings were that the occupationbased group was an acceptable and beneficial intervention for reducing parent-rated and clinician-rated symptoms of anxiety while increasing functioning. This was not a randomised controlled trial and the sample size was small; therefore, the changes reported cannot be attributed solely to the intervention. Findings from this study support the use of this intervention and more in-depth systematic research into the intervention s effectiveness is indicated. Acknowledgements Many children and families are gratefully acknowledged for participating in this study. The support of our clinical team and the District Health Board and British Journal of Occupational Therapy January (1) 35

6 An occupation-based group for children with anxiety academic support for the first author from Auckland University of Technology were also greatly appreciated. This study was supported financially by the New Zealand Association of Occupational Therapists Research and Education Grant and the Maurice and Phyllis Paykel Scholarship Trust. Conflict of interest: None declared. Key findings The occupational nature of the intervention was acceptable for children aged years. The intervention was found to reduce parent-rated symptoms of anxiety and to increase parent-rated and clinician-rated levels of child functioning. What the study has added Evaluation of this occupationally driven intervention for children with anxiety contributes to the limited pool of evidence-based interventions available to occupational therapists and other mental health professionals in CAMHS. References Achenbach T (1991) Manual for the child behaviour checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont, Department of Psychiatry. Beck J, Beck A, Jolly J, Steer R (2005) Beck Youth Inventories for Children and Adolescents, 2nd edition. San Antonio, TX: Harcourt Assessment. Christiensen H, Pallister E, Smale S, Hickie I, Calear A (2010) Community-based prevention programs for anxiety and depression in youth: a systematic review. Journal of Primary Prevention, 31(3), Costello E, Mustillo S, Erkanli A, Keeler G, Angold A (2003) Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), Csikszentmihalyi M (1993) Activity and happiness: towards a science of occupation. Journal of Occupational Science, Australia, 1(1), Ebb E, Coster W, Duncombe L (1989) Comparison of normal and psychosocially dysfunctional male adolescents. Occupational Therapy in Mental Health, 9(2), Flannery-Schroeder E, Choudhury M, Kenall P (2005) Group and individual cognitive-behaviour treatments for youth with anxiety disorders: 1-year follow up. Cognitive Therapy and Research, 29(2), Friedberg RD, Crosby LE, Friedberg BA (2000) Ward, I m worried about the beaver: issues in early identification and intervention with children experiencing depression and anxiety. Journal of Cognitive Psychotherapy, 14(1), Furman B (2004) Kids skills: playful and practical solution-finding with children. Bendigo, VIC: St Luke s Innovative Resources. Garfield S (1994) Research on client variables in psychotherapy. In: A Bergin, S Garfield, eds. Handbook of psychotherapy and behavior change. 4th ed. Oxford: Wiley, Gowers SG, Harrington RC, Whitton A, Beevor A, Lelliott P, Jezzard R, Wing JK (1999) Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA): Glossary for HoNOSCA score sheet. British Journal of Psychiatry, 174, Huebner D (2007) What to do when you grumble too much: a kid s guide to overcoming negativity. Washington, DC: Magination Press. Keller J, Kafkes A, Basu S, Federico J, Kielhofner G (2005) Child Occupational Self Assessment (COSA) Version 2.1. Chicago: University of Illinois, College of Applied Health Sciences, Department of Occupational Therapy, MOHO Clearinghouse. King G, Law M, King S, Hurley P, Hanna S, Kertoy M, Rosenbaum P, Young N (2004) Children s Assessment of Participation and Enjoyment (CAPE) and Preferences for Activities of Children (PAC). San Antonio, TX: Harcourt Assessment. Krupa T, McLean H, Eastabrook S, Bonham A, Baksh L (2003) Daily time use as a means of community adjustment for persons served by assertive community treatment teams. American Journal of Occupational Therapy, 57(5), Mandel D, Jackson J, Zemke R, Nelson L, Clark F (1999) Lifestyle redesign: implementing the Well Elderly Program. Bethesda, MD: American Occupational Therapy Association. Merrick W (1992) Dysphoric moods in depressed and non-depressed adolescents. In: M devries, ed. The experience of psychopathology: investigating mental disorders in their natural setting. Cambridge: Cambridge University Press, Smith NR, Kielhofner G, Watts JH (1986) The relationships between volition, activity pattern, and life satisfaction in the elderly. American Journal of Occupational Therapy, 40(4), Schaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S (1983) A children s global assessment scale (CGAS). Archives of General Psychiatry, 40(11), Silverman W, Treffers P (2001) Anxiety disorders in children and adolescents: research, assessment and intervention. Cambridge: Cambridge University Press. Silverman W, Kurtines W, Ginsburg G, Weerns C, Lumpkin P, Carmichael D (1999) Treating anxiety disorders in children with group cognitive behaviour therapy: a randomised clinical trial. Journal of Consulting and Clinical Psychology, 67(6), Tomb M, Hunter L (2004) Prevention of anxiety in children and adolescents in a school setting: the role of school-based practitioners. Children and Schools, 26(2), Vitiello B, Rohde P, Silva S, Wells K, Casat C, Waslick B, Simons A, Reinecke M, Weller E, Kratochvil C, Walkup J, Pathak S, Robins M, March J; TADS Team (2006) Functioning and quality of life in the treatment for adolescents with depression study (TADS). Journal of the American Academy for Child and Adolescent Psychiatry, 45(12), Wood A, Trainor G, Rothwell J (2001) Randomised trial of group therapy for repeated deliberate self harm in adolescents. Journal of American Academy of Child and Adolescent Psychiatry, 40(11), Zhan-Waxler C, Klimes-Dougan B, Slattery M (2000) Internalising problems of childhood and adolescence: prospects, pitfalls and progress in understanding development of anxiety and depression. Development and Psychopathology, 12(3), British Journal of Occupational Therapy January (1)