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Balance treatment ameliorates anxiety and increases self-esteem in children with balance disorders

Orit Bart, Yair Bar-Haim, Einat Weizman, Avi Sadeh & Matti Mintz Tel Aviv University Israel

European DCD Conference, 2007

Balance and anxiety

Emotional stress is common among subjects with balance disorders


(Asmundson, Larsen, & Stein, 1998; Duncan, Martha, & Rolf, 1992)

Balance dysfunction also affects children's self-esteem


Children with DCD perceive themselves lower on social acceptance and physical competence
(e.g., Piek, Dworcan, Barrett, & Coleman, 2000; Schoemaker & Kalverboer, 1994).

European DCD Conference, 2007

Balance and anxiety


parabrachial nucleus

limbic structures Amygdala Hypothalamus

Vestibular Proprioceptive Visual information

European DCD Conference, 2007

Balance and anxiety


Neither the clinical data nor the neurological models resolve the question of causality in the co-morbidity of balance and anxiety disorders.

European DCD Conference, 2007

Aims

To test the effectiveness of a structured balance treatment on balance functions


Whether improvement in balance leads to alleviation of anxiety and increase in selfesteem Thus, testing the hypothesis that balance dysfunction may serve a causal role in anxiety and self-esteem.

European DCD Conference, 2007

Methods

Participants

Forty-nine children (M=5.6,Range =5.07.0) with balance difficulties (BOTMP) and high level of anxiety (FSSC). Exclusion criteria: tactile difficulties (above clinical cutoff score on the TIE), or psychological or OT treatment during the 3 years preceding study onset.
European DCD Conference, 2007

Measures

Balance functions
Bruininks, 1978)

The Balance Subtest of the BruininksOseretsky Test of Motor Proficiency (BOTMP;

Vestibular Processing Scale of the Sensory


Profile Questionnaire (Dunn, 1999)

European DCD Conference, 2007

Measures

Anxiety

Fear Survey Schedule for Children (FSSC; Anxiety/Depression subscale of the Child
Behavior Checklist (CBCL; Achenbach, 1991)
Ollendick, 1983)

European DCD Conference, 2007

Measures

Self-esteem

The Pictorial Scale of Perceived Competence


and Social Acceptance for Young Children
(Harter & Pike, 1984)

European DCD Conference, 2007

Methods

Procedure
The treatment group (n=25; 3 girls) and the control group (n=24; 3 girls) did not differ in age, balance function, anxiety, and self-esteem at the time of assignment
Children were assigned to either a balance treatment group, or a waiting-list control group based on first come first served policy

European DCD Conference, 2007

Procedure
Battery assessment to both groups
Balance treatment group 12 weekly sessions Control group
Waiting list

Battery assessment to both groups


Intervention
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Intervention

Each session lasted 45-minutes and consisted of :

flexor and extensor muscle tone training maneuvers requiring balance maintenance in different body postures activity involving vestibular stimulation in different
head and body positions.

10% of the sessions were randomly monitored by other OTs. No deviations from protocol were detected.
European DCD Conference, 2007

Intervention

European DCD Conference, 2007

Results
Treatment Group Pre-treatment Post-control Balance function Balance Vestibular processing Anxiety FSSC Total CBCL Anxious/Depressed Self-esteem Self-Esteem Performance Self-Esteem - Acceptance 30.0 (6.2) 30.7 (6.4) 40.1 (4.1) 36.2 (6.2) 28.5 (4.8) 26.3 (6.5) 28.5 (4.6) 25.3 (5.9) 184.0 (11.3) 16.6 (5.5) 128.1 (9.3) 5.0 (2.4) 187.5 (7.3) 14.2 (4.8) 185.3 (8.9) 15.6 (4.7) 3.3 (1.9) 25.2 (3.9) 14.0 (3.7) 46.4 (2.9) 3.9 (2.2) 26.1 (4.8) 2.9 (2.0) 24.8 (3.7) Control Group Pre-waiting Post-waiting

European DCD Conference, 2007

Results
BALANCE
20

Balance - BOTMP

15 control Treatment

10

0 1 Time 2

treatment group, t(24)=16.1, p<.001


control group t(23)=3.9, p<.001
European DCD Conference, 2007

Results
ANXIETY
20

Anxiety - CBCL

15 control Treatment

10

0 1 Time 2

Treatment group t(24)=13.3, p<.001


control group t(47)=10.0, p<.001
European DCD Conference, 2007

Results
SELF- ESTEEM
50

Self-estemm

40 30 20 10 0 1 Tim e 2 control Treatment

Treatment group t(24)=8.4, p<.001


Control group t(23)=2.0, p=.06

European DCD Conference, 2007

Discussion
Balance treatment

Improved Balance

Reduced anxiety

Increased self-esteem

European DCD Conference, 2007

Discussion

These results land support to a causal pathway by which balance dysfunction is the driving force of a considerable portion of the variance in anxiety and low self-esteem in children with balance dysfunction

European DCD Conference, 2007

Discussion

Anxiety in 40% of the children in the treatment group were still above the clinical cutoff on the CBCL. The residual anxiety could be associated with non-balance factors:

Cognitive biases Inhibited temperament Dysfunctions in other neural circuits not


related to balance
European DCD Conference, 2007

Discussion

The amelioration of anxiety may be the outcome of a psychological desensitization process that is embedded in the balance treatment The positive and rewarding attitude of the therapist may contributed to reduction in anxiety and increase in self-esteem.
The potential change in parents' understanding of their childs difficulties might have lead to more supportive attitude toward the child
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Further studies

To include another control group who will receive another treatment method To assess whether anxiety treatment will improve balance function

European DCD Conference, 2007

Clinical implications

Clinical assessment of anxiety disorders in children should include screening for an underlying balance disorder. If an underlying co-morbid balance disorder is identified then a tailored balance intervention may be integrated into the treatment plan.

European DCD Conference, 2007