Treatment for Minority Emerging Adults with Anxiety Disorders

Treatment for Minority Emerging Adults with Anxiety Disorders M. Carolina Zerrate, M. D. , M. H. S. Assistant Professor of Psychiatry Medical Director, Youth Anxiety Center–Washington Heights Division of Child and Adolescent Psychiatry New York-Presbyterian/Columbia University Medical Center August 19, 2017 1

Objectives • Participants will recognize developmental needs of emerging adults with mental health disorders, including those of racial/ethnic minority backgrounds. • Participants will be able to describe main components of a developmentally informed intervention for minority emerging adults, as illustrated by cases treated due to the presence of anxiety disorders. 2

Outline • • Emerging adulthood: The stage of ‘in-between’ The nature of anxiety and anxiety disorders Evidenced based treatment for anxiety disorders Introduction to Launching Emerging Adults Program (LEAP) – LEAP model and expanded LEAP model – Clinician tools 3

No Disclosures

Emerging Adulthood • J. J. Arnett (2000): New Developmental Stage o “Group-level phenomenon: age of ‘in between, ’ search for identity, possibilities; time of instability and self-focus” • New considerations include: o Longer duration and multiple pathways o Unique developmental challenges 1950 s High school Career/Marriage Career Arnett, J. J. (2000). Emerging adulthood: A theory of development from the late teens through the twenties. American psychologist, 55(5), 469. Independent adult

Emerging Adulthood in Minority Populations African Americans, Asians, Hispanics in the US • Share views of independence with white emerging adults • Favor view of obligations to others (family) compared to white emerging adults Bicultural conception of transition to adulthood 6

DEVELOPMENTAL MILESTONES Bicultural demands Self-care • Grooming • Cooking • Medical care • Laundry • Healthy diet & sleep habits Recreation • Seek out experiences • Participate in cultural events • Organize meet ups and trips • Exercise for self-care Finances Relationships • Open/manage back account • Earn own money • Pay rent/bills • Make/maintain relationships • Friendships, romantic relationships, family Emotional Independence • Express thoughts and feelings • Regulate emotions • Accept responsibility for mistakes CULTURAL STRESS Independent Tasks • Travel alone • Schedule appointments • Make long-term decisions • Manage medications School/Work • Homework • Complete high school • College applications • Registering for classes • Looking for a job Personal values • Defines Identity: • Self • Gender & Sex • Cultural • Independent opinions: Voting ACCULTURATION

Why focus on Emerging Adulthood ? Emerging Adulthood: Critical developmental stage to acquire the skills and strengths needed for a successful transition into adulthood ? Child and adolescent studies do not include individuals >18 Studies may include young adults but under a general “adult” umbrella “Investing in the Health and Well-Being of Young Adults” (Institute of Medicine, 2015): Adult studies often do not have a specific focus on the 18 -25 population.

Why focus on Anxiety? Lifetime prevalence of psychiatric disorders in childhood and adolescence Merikangas, K. R. , He, J. , Burstein, M. , Swanson, S. A. , Avenevoli, S. , Cui, L. , … Swendsen, J. (2010). Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry , 49(10), 980– 989.

Anxiety Disorders and Emerging Adulthood in the U. S. Adolescents Lifetime Prevalence 22. 3 % Access to treatment 21. 7 % Latino adolescents receive 4 times less service per lifetime prevalence than white adolescents Wang, P. S. , Lane, M. , Olfson, M. , Pincus, H. A. , Wells, K. B. , & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of general psychiatry, 62(6), 629 -640. Merikangas, et al. Lifetime prevalence of mental disorders in U. S. adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct; 49(10): 980 -9 Merikangas, et al. Service utilization for lifetime mental disorders in U. S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011 Jan; 50(1): 32 -45

What is Anxiety • It’s a normal emotion in response to fearful or stressful situations that helps us mentally and physically to overcome these situations.

When is Anxiety a problem? IMPAIRMENT : hts So P e g v m hy iti ou at n th ic sic g o co al C tive m : a pl g ai e ns N ANXIETY DISORDER Behavioral: Avoidance Adapted from Sarrubi & Pimentel (2012)

Evidence Based Treatments for Anxiety Disorders Child/Adolescent Anxiety Multimodal Study CAMS Acute Outcomes (n=488) Walkup, Albano et al. , 2008 Minorities and Latinos can benefit from evidence-based treatments

Re ns ai pl m n co io ic at at lax m So Co Neg gn at iti ive ve th re ou fra gh m ts in g Cognitive Behavioral Therapy ANXIETY DISORDER Avoidance Problem solving & Graded Exposure Adapted from Sarrubi & Pimentel (2012)

Cognitive Behavioral Therapy core components THOUGHTS BEHAVIOR EMOTIONS • Identify dysfunctional thinking (automatic negative thoughts) • Examine the validity and usefulness of thoughts • Gain more adaptive and accurate perspectives • Reframing thoughts • Experience with coping and problem solving • Exposure exercises

Psychopharmacological treatment for anxiety disorders • First line of treatment • Selective Serotonin Reuptake Inhibitors (SSRIs) • “Antidepressants” • Considered largely safe despite Black Box Warning • Monitored closely by medical provider • At least six months to one year • Adjunctive treatment: • Sleep, acute and severe anxiety, persistent debilitating anxiety

Long Term Outcomes of Evidence Based Treatments for Anxiety Disorders Child/Adolescent Anxiety Multimodal Extended Long term Study (CAMELS) • • • Six years post CAMS 288 Ages 11 -26 y. o. Nearly 50% Relapsed Ginsberg et al. , JAMA Psychiatry, on-line 1. 29. 2014 What happened? Development was not addressed Symptom improvement Improved function

Launching Emerging Adulthood Program LEAP • Incorporates empirically-supported, cognitivebehavioral treatments for anxiety with developmentally-informed components • Intended to increase self-sufficiency and encourage appropriate parental involvement Albano, AM, Poznanski, B, et al. (in preparation). The Launching Emerging Adult Program Manual and Guides. Columbia University Medical Center, New York, NY.

LEAP Developmental Model Anxiety is maintained through avoidance, escape & withdrawal Parental overprotection (POP) or overcontrol Stalled developmental tasks Failure to launch

LEAP Developmental Model Expanded Anxiety is maintained through avoidance, escape & withdrawal Parental overprotection (POP) or overcontrol Disengaged Parent or lack of support Stalled developmental tasks Failure to launch

LEAP Model Targets for Emerging Adult with Anxiety: Avoidance behavior Cognitive distortions Physiological arousal Stalled developmental tasks Patient. Focused CBT: Individual and/or group Parent Behavioral Targets: Overprotection Overcontrol Inconsistent contingencies Modeling and reinforcement of escape and avoidance Rescue from negative outcomes History of anxiety Parental beliefs/attitudes Patient-Parent Transition Sessions: Transition Sessions target anxiety and stalled development by addressing patient and parent behaviors and emotions Note: From Guerry, Hambrick & Albano (2015). A version of this figure appears in Detweiler, M. F. , Comer, J. , Crum, K. I. , & Albano, A. M. (2014). Social anxiety in children and adolescents: Biological, psychological, and social considerations. In S. G. Hofmann & P. M. Di. Bartolo (Eds. ), Social phobia and social anxiety: An integration (3 nd Ed). New York: Elsevier Press.

LEAP Model Targets for Emerging Adult with Anxiety: Avoidance behavior Cognitive distortions Physiological arousal Stalled developmental tasks Patient. Focused CBT: Individual and/or group Parent Behavioral Targets: Inconsistent contingencies Modeling and reinforcement of escape and avoidance History of anxiety Parental beliefs/attitudes Patient-Parent Transition Sessions: Transition Sessions target anxiety and stalled development by addressing patient and parent behaviors and emotions Note: From Guerry, Hambrick & Albano (2015). A version of this figure appears in Detweiler, M. F. , Comer, J. , Crum, K. I. , & Albano, A. M. (2014). Social anxiety in children and adolescents: Biological, psychological, and social considerations. In S. G. Hofmann & P. M. Di. Bartolo (Eds. ), Social phobia and social anxiety: An integration (3 nd Ed). New York: Elsevier Press.

Modified LEAP Treatment Model: Disengaged Parent Targets for Emerging Adult with Anxiety: Avoidance behavior Cognitive distortions Physiological arousal Stalled developmental tasks Patient. Focused CBT: Individual and/or group Motivation (MI) Emotion regulation & Interpersonal skills Parent Behavioral Targets: Disengagement Lack of support Inconsistent contingencies Modeling and reinforcement of escape and avoidance History of anxiety Parental beliefs/attitudes Outreach & Cultural Competence : Identify “surrogate parent” Address barriers to treatment Patient-Parent Transition Sessions: Robust psychoeducation Transition Sessions target anxiety and stalled development by addressing patient and parent behaviors and emotions Note: From Guerry, Hambrick & Albano (2015). A version of this figure appears in Detweiler, M. F. , Comer, J. , Crum, K. I. , & Albano, A. M. (2014). Social anxiety in children and adolescents: Biological, psychological, and social considerations. In S. G. Hofmann & P. M. Di. Bartolo (Eds. ), Social phobia and social anxiety: An integration (3 nd Ed). New York: Elsevier Press.

Clinician’s Tool kit • Fear and avoidance hierarchy LEAP FRAMEWORK • Developmental Hierarchy • Scaffolding form Evidenced Based Practice: Cognitive Behavioral Therapy Dialectical Behavioral Therapy Trauma Informed Care

LEAP Tool kit

TASK BEHAVIORAL INDICATORS Establish emotional independence from parents Soothes self when confronted with disappointment or challenge; Seeks advice appropriately and weighs options; Able to own feeling states and reactions Develop self-identity Affirmatively describes self in terms of aspirations, interests, abilities and skills; Recognizes own limits Integrating Developmental Framework Establish behavioral independence from parents Completes tasks on own; Takes initiative; Asserts self to meet needs Manage money responsibly Spends money in relation to budget and awareness of meeting responsibilities; Makes own purchases for food, clothing, and other needs; Manages finances so that relaxation/hobbies/interests are pursued with little financial tension Make and keep long term friendships Engages with others and pursues relationships on own Control personal self-care Regulates own sleep patterns; Aware of and engages in healthy diet and exercise routine; Self-soothes appropriately Control personal medical/health care Makes regular appointments in timely way (annual physical; mental health visits); Seeks health care consultations as needed and in timely way; manages medications on own Engage and accept sexual identity Is engaged in pursuing sexual knowledge and understands own sexual identity; Accepts sexual identity Form romantic relationships Has interest in and pursues romantic partner(s) in a healthy and meaningful way Formulate and engage in long-term vocational goals Able to articulate interests and pursue education or training in areas related to the interest; Develops set of skills/abilities to pursue goals Complete educational requirements Completes compulsory educational requirements of high school or equivalent; Seeks further education to pursue goals for career/vocation Establish financial independence Earns and saves own money Lives independently Moves away from home (potentially in stages, such as for college or with housemates until independent); Establishes own residence and maintains all aspects (financial, upkeep) on own

Integrating Developmental Framework Going to the hospital Going outside Clean my room Open the door Walk around the house Going to pick up my medications Going to do my laundry Sometimes take out the trash Grooming and hygiene Prepare sandwich Choose my clothes Homework Take medications Scheduling appointments Communicating with providers Cooking Socializing Managing finances Driving places or taking public trasnportation Reminders for appointments

Conclusions • Incorporating a developmental framework is essential for treatment of mental health disorders among emerging adults • The Launching Emerging Adult Program offers an innovative and unique treatment model for the treatment of emerging adults targeting functional recovery and supporting rehabilitation.

Youth Anxiety Center–Washington Heights (YAC-WH) Division Director: Jeremy Veenstra-Vanderweele, MD Division Clinical Director: Laura Mufson, Ph. D. Clinic Co-Directors: Cristiane Duarte, Ph. D. , M. P. H. , & Anne Marie Albano, Ph. D. Director of Clinical Services: Warren Ng, M. D. Associate Director of Clinical Services: Erica M. Chin, Ph. D. Medical Director: Carolina Zerrate, M. D. , M. H. S Psychologists: Rebecca Erban, Psy. D. , & Jazmin Reyes, Ph. D. Research Coordinator: Ana Ortin, Ph. D. ; T 32 Fellow: Chiaying Wei, Ph. D.

For more information M. Carolina Zerrate, MD maz 9034@nyp. org LEAP Manual and materials are in development. Please use citation: Albano, AM, Poznanski, B, et al. (in preparation). The Launching Emerging Adult Program Manual and Guides. Columbia University Medical Center, New York, NY. http: //www. nyp. org/youthanxiety