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Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

Weighted Vest Use in an Individual with Generalized Anxiety Disorder


Paul D. Sroka
Sacred Heart University

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

The prevalence of symptoms related to anxiety in children is significant. In the United


States, between 10% and 20% of children meet diagnostic criteria for an anxiety disorder
however, many more suffer from symptoms but do not meet the standards to be diagnosed
(American Academy of Child & Adolescent Psychiatry, 2015). This is a concern for occupational
therapists working in the pediatric population. Excessive anxiety can impact children
functionally and disrupt occupations including education, play, social participation and leisure.
Occupational therapists are qualified through education and training in a variety of methods to
help children manage the feelings associated with anxiety to more effectively participate in
disrupted occupations.
Childhood generalized anxiety disorder (GAD), once known as overanxious disorder
(OAD) in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III),
presents as excessive anxiety of at least 6 months duration, occurring most days, and that is
hard to control, not focused on a specific situation or objects, and not triggered by recent
stressful events (Andrews et al., 2010; Masi et al., 2004, p. 752). Anxiety in children diagnosed
with GAD is diverse and can include worries about educational performance, natural phenomena
including storms or natural disasters, social environments, a heightened sensitivity to criticism,
and a need to be comforted. Children with anxiety may be passive or fearful and underestimate
their abilities (American Academy of Child & Adolescent Psychiatry, 2015). Additionally, GAD
shares similar symptoms, including impaired concentration and distractibility, with disorders
such as attention deficit hyperactivity disorder and autism (Hodgetts, Magill-Evans, &
Misiaszek, 2010; Masi et al., 2004; VandenBerg, 2001).
Traditionally, anxiety disorders have been managed using cognitive behavioral therapy
(CBT) and medications to target the overactive amygdala (Wehry, Beesdo-Baum, Hennelly,

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

Connelly, & Strawn, 2015). Many cognitive behavioral methods can be used to target
generalized anxiety disorder including but not limited to intense psychotherapy, relaxation
training and deep breathing techniques for managing somatic symptoms, mindfulness exercises,
and cognitive restructuring of the anxiety provoking thought (Wehry et al., 2015). Another
intervention used to target anxiety is the use of medications. Originally, tricyclic antidepressants
were prescribed but these have been replaced by selective-serotonin reuptake inhibitors (SSRIs)
and selective-serotonin norepinephrine reuptake inhibitors (SSNRIs) (Wehry et al., 2015).
Medications that have been tolerated well in individuals with anxiety include Fluoxetine,
Paroxetine, Venlafaxine extended release, and Sertraline. CBT and Sertraline used together have
been particularly effective (Wehry et al., 2015).
The use of weighted vests have been used almost exclusively in children with autism and
attention deficit hyperactivity disorder (ADHD) however, they could have application in the use
of children with generalized anxiety disorder who experience impairments in processing sensory
stimuli (Miller, Coll, & Schoen, 2007). Weighted vest use is based off Anna Jean Ayres Sensory
Integration theory (Lin, Lee, Change, & Hong, 2014). One of the key principles in Ayress
theory states that, for learning in a child to occur, his or her central nervous system (CNS) must
register sensory input accurately and process that input effectively so that he or she may
respond to it in an organized and adaptive way (Ayres, 1972, as cited in Olson & Moulton,
2004, p. 46). The purpose of a weighted vest is to provide somatosensory input directly to the
CNS (Olson & Moulton, 2004). Sensory stimuli from the environment stimulate the reticular
formation to varying degrees in children with generalized anxiety disorder, autism, and ADHD.
Deep pressure provided by a weighted vest is very effective in decreasing the heightened level of
arousal in the reticular formation (Ayres, 1972, as cited in VandenBerg, 2001). Additionally,

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

somatosensory deep pressure from a weighted vest is transmitted indirectly to Purkinje cells
located in the cerebellum. These cells also help to decrease the level of arousal in the reticular
formation through the release of serotonin into the blood, producing a calming effect (Edelson,
1999).
Research into the use of weighted vests and their effects on inattention to task, fidgeting,
and in-seat behavior is relatively knew with mixed results regarding their efficacy. Cox et al., in
an alternating treatment study, examined the effects of weighted vest use on in-seat behavior
(2009). In their study, in-seat behavior duration did not increase with the use of a weighted vest.
Similarly, Quigley et al. found no effect with weighted vest use on in-seat behavior, also called
leaving the work area, while working on school tasks (2011). This is in contrast to Buckle et al.
who conducted a longitudinal study examining in-seat behavior and attention to task. Thirty
children participated and demonstrated slight improvement for in-seat behavior and attention to
task.
In an AB design with four subjects diagnosed with ADHD, the use of a weighted vest
while performing fine motor tasks improved subjects attention to task (VandenBerg, 2001).
Similarly, a study of 110 students examining attention to task and fidgeting behaviors, defined as
extraneous body movements, showed significant improvements in each behavior (Lin, Lee,
Chang, & Hong, 2014). To support weighted vest use, participants in Fertel-Daly et al.s study
showed improvements in attention to task and fidgeting, defined as repetitive or stereotypical
mannerisms such as flicking or tapping, while wearing the weighted best (2001). Finally, other
research disputes the effectiveness of weighted vests on attention to task. A five subject ABA
design of children ages 2-4 with attentional difficulties did not produce results supporting the
efficacy of weighted vest use.

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

Research using weighted vests to target difficult behaviors such as inattention to task,
fidgeting, and in-seat behavior is limited with severely mixed results as to their effectiveness or
lack of effectiveness. Due to limited research and the mixed results of studies that were
conducted as to the effectiveness of the use of weighted vests, this proposal study seeks to add to
the literature and clarify weighted vest efficacy.
Methods
Subjects
The participant will be one ten-year-old male diagnosed with generalized anxiety
disorder. The participant will be normally developing and is not receiving special education
services or have had past psychological and medication management of the diagnosed condition.
He will be English speaking and have the ability to maintain sufficient attention to participate in
a thirty minute evening family meal once daily. He will be excluded as a participant if he has
aggressive or violent episodes while at any point during evening meals.
Settings and Materials
Each baseline and intervention session will occur in the childs home while consuming
dinner as unfamiliar or novel situations can generate feelings of anxiety or nervousness in
children with anxiety. The materials used for the intervention will be provided by the examiner.
Two identically OTvests will be provided. One vest will be unweighted for use during the
baseline phase. The second vest will be weighted for the treatment phase (see appendix for
weighted vest link and purchasing information). A camera for recording targeted behaviors will
also be provided.

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

Design
The study will use an A-B-A-B design. The independent variable is the use of a weighted
vest and the dependent variables are fidgeting, in-seat behavior, and attention to task.
Procedure
Baseline and treatment sessions examining targeted behaviors will occur over four weeks.
The first baseline phase (A) will occur over a period of one week and consist of one session per
day from Monday to Friday. After baseline, the treatment phase (B) will occur with the same
duration and frequency as the baseline phase. Following the first treatment phase, this process
will be repeated with the same duration and frequency as before. Prior to the family meal,
parents will put the vest on with or without weight, depending on the phase, without the raters
knowing which vest is being used. After the subject is wearing the vest and at the beginning of
the meal, a camera, placed unobtrusively, will begin recording and two raters will document
targeted behaviors five minutes after dinner begins for ten minutes.
Intervention
The intervention will consist of ten dinner sessions over two weeks. These sessions will
be thirty minutes in duration, using the weighted vest provided by examiners. The intervention
will be completed by the parents who will be trained by the two raters making the observations.
Outcome Measures
The outcome measures of the DV with weighted vest use will include in-seat behavior,
fidgeting, and attention to task. These will be defined as follows:

In-seat behavior the subject must sit at the table with all four legs of the chair touching
the ground. The subjects bottom must be touching the desk chair and must not be more

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

than two inches off the chair bottom and for longer than five seconds. Additionally, both
feet must be touching the floor. Examples will include sitting with both feet on the floor
facing forward and reaching (rising less than two inches from the chair for less than five
seconds) for food and/or drinks before sitting back down. Non examples will include
raising more than two inches off the chair bottom, rising for more than two seconds, or
tilting back in the chair.

Fidgeting small and observable extraneous, non-purposeful, stereotypic movements


unrelated to the task at hand (consuming a family meal) using the hands and/or feet for at
least five seconds. Examples will include hair twirling, hand wringing, twitches, and foot
tapping lasting five seconds or longer. Non examples will include cracking knuckles,
stretching in-seat, and picking at the skin or clothing, for less than five seconds.

Attention to task maintaining conversation with parents relative to whichever topic is


being discussed, and eating provided food. Examples will include staying on
conversation topic for longer than ten seconds and completely finishing the meal with no
leftovers. Non examples will include irrelevant conversation, not being able to
maintain conversation for longer than ten seconds, and a meal that is not fully consumed.

In-seat behavior, fidgeting, and attention to task will be measured using ten second partial
interval time sampling for ten minutes in both baseline and treatment phases. All sessions will be
videotaped and behaviors recorded by two trained raters who are blind to which phase of
treatment they are observing. Raters will also be unaware of which five minute distribution that
will be used in the results for both baseline and intervention.
Analysis
Graphing of in-seat behavior, fidgeting, and attention to task for the subject will be used
for visual analysis of the results. The diagram pictured below displays sample graphing of
fidgeting behaviors during baseline and treatment phases. It is hypothesized that the use of a
weighted vest will lead to improvements in all dependent variables.

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

IOA
As all sessions in both phases will be video recorded, 100% of tapes will be assessed by
two raters, separately, with ten years of rating experience for IOA on all three dependent
measures. Raters will be trained using videos of child actors demonstrating targeted behaviors.
Additionally, both raters will be trained to 90% IOA agreement using a percentage agreement
index.
Treatment Fidelity
Weighted vest intervention will be examined for treatment fidelity in 40% of videotaped
intervention sessions. Videos of the chosen sessions will be viewed to ensure that recordings
occur Monday through Friday and not Saturday and Sunday. Additionally, the time stamp of the
video will be noted to be sure sessions are being implemented at the appropriate time (dinner
time). Finally, parents will sign a checklist stating that they have ensured the correct amount of
weight is in the vest. Any data that deviates from the session day, time of day, and length of
observation will be discarded.

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

References
American Academy of Child & Adolescent Psychiatry (2015). Anxiety disorders in children and
adolescents [PowerPoint slides]. Retrieved from
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urces_for_medical_student_educators/Anxiety%20Disorders%20in%20Children.ppt.
Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G.,
Rapee, R. M., Ruscio, A. M., & Stanley, M. A. (2010). Generalized worry disorder: A
review of dsm-iv generalized anxiety disorder and options for dsm-v. Depression and
Anxiety, 0, 1-14.
Buckle, F., Franzsen, D., & Bester, J. (2011). The effect of the wearing of weighted vests on the
sensory behaviour of learners diagnosed with attention deficit hyperactivity disorder
within a school context. South African Journal of Occupational Therapy, 41(3), 36-42.
Collins, A., & Dworkin, R. J. (2011). Pilot study of the effectiveness of weighted vests.
American Journal of Occupational Therapy, 65(6), 688694. doi:
10.5014/ajot.2011.000596.
Cox, A. C., Gast, D. L., Luscre, D., & Ayres, K. M. (2009). The effect of weighted vests on
appropriate in-seat behaviors of elementary-age students with autism and severe to
profound intellectual disabilities. Focus on Autism and Other Developmental Disabilities,
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Edelson, S. M., Edelson, M. G., Kerr, D. C. R., & Grandin, T. (1999). Behavioral and
physiological effects of deep pressure on children with autism: A pilot study evaluating
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Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

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Fertel-Daly, D., Bedell, G., & Hinojosa, J. (2001). Effects of a weighted vest on attention to task
and self-stimulatory behaviors in preschoolers with pervasive developmental disorders.
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Hodgetts, S., Magill-Evans, J., & Misiaszek, J. E. (2011). Weighted vests, stereotyped behaviors,
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disorder. American Journal of Occupational Therapy, 68(2), 149158.
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Quigley, S. P., Peterson, L., Frieder, J. E., & Peterson, S. (2011). Effects of a weighted vest on
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disorders. Research in Autism Spectrum Disorders, 5, 529-538.

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VandenBerg, N. L. (2001). The use of a weighted vest to increase on-task behavior in children
with attention difficulties. American Journal of Occupational Therapy, 55(6), 621628.
Wehry, A. M., Beesdo-Baum, K., Hennelly, M. M., Connolly, S. D., & Strawn, J. R. (2015).
Assessment and treatment of anxiety disorders in children and adolescents. Current
Psychiatry Report, 17(7), 1-19.

Running head: GENERALIZED ANXIETY DISORDER AND WEIGHTED VESTS

Appendix
Weighted Vest
OTvest http://otvest.com/

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