1. Comorbidity of childhood balance and anxiety disorders: treatment and theory Ph.D. study by Orit Erez

2. Comorbidity of balance and anxiety disorders A recent special issue of the J. of Anxiety Disorders, reviewed the experimental and clinical findings related to comorbidity of balance disorders and anxiety (Sklare et al., 2001).

3. Comorbidity of balance and anxiety disorders Causality ???? Balance disorder Anxiety disorder Balance disorder ~ Anxiety disorder Balance disorder Anxiety disorder We are interested in this option

4. Balance disorder as the origin of balance and anxiety comorbidity Theoretical implication: Anxiety evolves from normal limbic system that responds excessively to interaction with deficient balance system. Clinical implication: Successful balance treatment may ameliorate also the anxiety symptoms.

5. Checking for comorbidity in childhood In children with anxiety as primary disorder. In children with balance as primary disorder.

6. Comorbidity with anxiety as primary disorder Is childhood anxiety associated with poor balance performance ? ( Erez et al., J. of Anxiety Disorders, 2003)

7. Subjects Exclusion criteria: no past history of acute vestibular disorder or chronic ear disease.

8. Procedure in chronological order:  DSM-IV based diagnosis of anxiety disorder by a psychiatrist.  Elevated anxiety confirmed on Fear Survey Schedule for Children (FSSC; Ollendick, 1983).  Neurological and neuro-otological examination by a neurologist.  Static and dynamic balance tests by a movement therapist (Orit Erez).  Dizziness & motion sickness questionnaires.

9. Results Children with anxiety disorders vs. controls:  Reported more dizziness episodes (80 vs. 40%).  Reported enhanced sensitivity to motion sickness provoking situations.  Were hypersensitive to the rotary chair test.

10. Children with anxiety disorders had more balance mistakes relative to controls *p<0.05; **p<0.01; ***p<0.001 Interaction G by M G roup effect M anipulation effect Test ns Floor-bench ns Eyes open-closed ** Stand heel-to-toe * ns Floor-bench-trampoline *** Eyes open-closed *** Stand on one-foot ns*Head still-nodding * Stand on cylinder ns Eyes open-closed *** Walk on cubicles ns * *Normal-heel-to-toe *** Eyes open-closed *** Walk on rope

11. Time to task completion was longer in children with anxiety disorders relative to controls Interaction G by M G roup Effect M anipulation effect Test ns Eyes open-closed *** Walk on cubicles ns * *Bench-rope ** Normal-heel-to-toe *** Eyes open-closed *** (Surface by Walking) Walk on rope ns**Spinning straight-bent ns Walk on rope *p<0.05; **p<0.01; ***p<0.001

12. Is childhood anxiety associated with poor balance performance ? Yes !!!

13. Comorbidity with balance as primary disorder Are children with poor balance performance more anxious than normal controls? Thesis by Moran Levin (2004)

14. Subjects

15. Inclusion criteria in clinical group: < normal balance performance (Bruininks 1978). Normal schooling system. Inclusion criteria in control group: No known balance difficulties. Exclusion criteria: Tactile difficulties (Royeen & Fortune, 1990). Previous psychological or occupational therapies. No other major developmental problems.

16. Procedure in chronological order:  Balance and anxiety were assessed upon arrival at the clinic.  Controls were tested at the school.  Testing and treatment were administered by a certified occupational therapist, experienced in sensory integration techniques (Moran Meidan).

17. Balance tests:  Balance sub-test of the Bruninks-Oseretsky Test of Motor Proficiency (Bruninks, 1978).  Vestibular scale of The Parental Sensory Profile Assessment (Dunn, 1999). Anxiety tests:  Anxiety-Depression Parental Scale of the Child Behavior Checklist (CBCL; Achenbach, 1991).  Fear Survey Schedule for Children – self report (FSSC; Ollendick, 1983).

18. Obvious result: Clinical < Controls on balance tests; p<.001. New result: Clinical > Controls on anxiety tests; p<.001.

19. Relation between parental report on balance and emotionality r=-.32 r=-.52*

20. Relation between balance performance and parental report on emotionality r=.03 r=-.72*

21. Relation between parental report on balance and self report on emotionality r=.14 r=-.31

22. Relation between balance performance and self report on emotionality r=-.52* r=-.63*

23. Are children with poor balance performance more anxious than normal controls? Yes !!!

24. Treatment of children with balance as primary disorder and elevated anxiety Can balance treatment alleviate the anxiety? Thesis by Einat Karmon-Weisman (2004)

25. Subjects

26. Inclusion criteria: normal self report on Fear Survey (Ollendick, 1983). Normal schooling system. Exclusion criteria: Tactile difficulties (Royeen & Fortune, 1990). Previous psychological or occupational therapies. No other major developmental problems.

27. Procedure in chronological order:  Balance and anxiety were assessed upon arrival at the clinic.  Half of the children received 12 weekly sessions of OT with sensory-motor orientation: Improvement of flexor and tensor muscle tone. Maintenance of balance in different postures. Vestibular stim in various positions, speeds & intensities.  Balance and anxiety were reassessed after the last treatment.  Testing and treatment were administered by a certified occupational therapist, experienced in sensory integration techniques (Einat Veisman-Carmon).

28. Balance tests:  Balance sub-test of the Bruninks-Oseretsky Test of Motor Proficiency (Bruninks, 1978).  Vestibular scale of The Parental Sensory Profile Assessment (Dunn, 1999). Anxiety tests:  Anxiety-Depression Parental Scale of the Child Behavior Checklist (CBCL; Achenbach, 1991).  Fear Survey Schedule for Children – self report (FSSC; Ollendick, 1983).

29. Balance (Bruninks-Oseretsky Test of Motor Proficiency) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 O O After treatment 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 O O Before treatment Treatment Control Group by Time: p<.001

30. Vestibular Processing (Parental Report) 10 20 30 40 50 O O After treatmentBefore treatment 0 10 20 30 40 O O Treatment Control Group by Time: p<.001

31. Anxiety Level (CBCL: Parental reports) 0.00 5.00 10.00 15.00 O O After treatment 0.00 5.00 10.00 15.00 O O Before treatment Treatment Control Group by Time: p<.001

32. Anxiety Level (Fear Survey Schedule for Children: Child Report) 0 50 100 150 O O After treatment 0 50 100 150 O O Before treatment Treatment Control Group by Time: p<.001

33. Can balance treatment alleviate the anxiety? Yes !!!

34. Theoretical background: Normal individual facing an aversive challenge Two stage theory of learning predicts: 1 st stage: Fast acquisition of fear response. 2 nd stage: Slow acquisition of motor response. Extension to three stage theory of learning: 3 rd stage: Extinction of fear response after acquisition of motor response.

35. Theoretical background: Individual with balance disorder facing balance challenging conditions Three stage theory of learning predicts: 1 st stage: Fast acquisition of fear response. 2 nd stage: No acquisition of balance restoration motor response. 3 rd stage: No extinction of fear response.

36. The next step: Treatment of children with anxiety as primary disorder and poor balance Select a group of children with generalized or separation anxiety. Test the group for comorbidity with balance deficiency. Provide a 2-3 months physical balance training. Test for improvement of balance skills. Test for a short and long-term amelioration of anxiety symptoms.