1. Childhood Anxiety Disorders

2. Anxiety
Anxiety: mood state characterized by strong, negative emotion and bodily symptoms in which an individual apprehensively anticipates future danger or misfortune
Fear: immediate alarm reaction to current danger
Anxiety disorder: excessive and debilitating anxiety with negative emotion and fear

3. Developmental Considerations
Anxiety is an adaptive emotion that readies children both physically and psychologically to cope with danger
Infancy: loud noises, being startled, strangers
Toddlerhood: dark, separation
School-Age: injury, natural disasters
Adolescence: competency-based concerns, health of self and others

4. Developmental Considerations
DSM-IV qualifiers for children
Anxiety may be expressed by crying, tantrums, freezing, or clinging
Unlike adults, children are not required to acknowledge that fears are unreasonable or excessive
Difficulties in recognizing symptoms
Internalizing symptoms less observable
Internalizing symptoms less aversive
Children may lack verbal skills to communicate concerns

5. Anxiety: 3 Interrelated Systems
Cognitive
Anxious thoughts develop in response to cognitive distortions in the attention, interpretation, and memory components of information processing
Physical
Brain sends messages to sympathetic nervous system: fight or flight response
Symptoms are excessive in intensity or duration
Behavioral
Action (or inaction) that individuals take to prevent exposure to feared stimuli or to reduce anxiety associated with exposure to the feared stimuli

6. Case Example
“Charlie, now 11 years old , is entering 6th grade in a middle school. Each September since kindergarten the start of school has always been a struggle for him. This year his distress escalated with the added demand of starting in a new school, and by November he missed twenty-six days of school. His academic work has suffered, and his teachers have sent his assignments home. Charlie insists that he can't complete them without his mother's presence. He worries that something bad may happen to his mom while he is in school.”

7. Separation Anxiety Disorder DSM Criteria: 3+ symptoms
Excessive distress when separation from attachment figure is anticipated
Excessive worry about losing or possible harm to figure
Excessive worry that an event will lead to separation
Reluctance or refusal to go to school because of separation fear
Excessive fear or reluctance to be alone
Reluctance or refusal to go to sleep without being near attachment figure
Nightmares involving theme of separation
Complaints of physical symptoms when separation occurs/is anticipated

8. SAD: Clinical Presentation
Demand parental attention
Clinging
Sleep with parents

9. Prevalence, Age of Onset, Family Characteristics
Prevalence rate of 2 - 4%
SAD accounts for 1/2 of all children and adolescents referred for treatment of anxiety disorders
Occurs as early as preschool age
No gender differences
Often occurs in response to some major stressor

10. Case Example
“Corinne's mother tried everything she could think of to get her 14-year-old daughter to join an after-school club or accept invitations to parties at classmates' homes. Corinne insisted that she would rather stay home and read; she didn't think she fit in with her friends any more and didn't know what to say to them. When she did venture out with a cousin, it took her hours to do her makeup because she didn't think she looked quite right.”

11. Social Phobia DSM Criteria
Marked and persistent fear of one or more social or performance situations in which child is exposed to unfamiliar people or possible scrutiny by others
The child fears he/she will act in a way that will be humiliating or embarrassing
Exposure to situation provokes considerable anxiety
Feared situations are avoided or else endured with intense anxiety and distress

12. Social Phobia: Clinical Features
A child with social phobia is one who displays phobic responses to one or more social situations:
Speaking, eating, or drinking in front of others
Initiating or maintaining conversations
Speaking to adult authority figures
Other situations that may elicit concerns over being embarrassed/humiliated

13. Social Phobia: Clinical Features
In young children, the anxiety may be reflected in signs of distress such as crying, throwing temper tantrums, or becoming mute and clinging to parents
In older children, it may be expressed less dramatically in terms of trembling hands, a shaky voice or other obvious signs of anxiety

14. Social Phobia: Clinical Features
Children with social phobias also experience anticipatory anxiety well before actually confronting these situation
Unfortunate cycle
Anticipate awkwardness/poor performance
Increased anxiety
Actual awkwardness/poor performance
Can interfere with the child's ability to function in a wide range of areas

15. Social Phobia: Associated Features
Children with social phobias can also show a range of associated features:
Being overly sensitive to criticism
Having low levels of self-esteem
Having inadequate social skills
School performance may be impaired due to test anxiety and failure to participate in classroom activities
Social anxieties can result in school refusal

16. Social Phobia: Prevalence
Relatively rare in the general child population
Prevalence estimates of around 1-3% are suggested by cross-sectional research
No gender differences
Last, et al. (1992) has suggested that among children referred to an anxiety disorders clinic, 20% met DSM criteria for a diagnosis of social phobia
Thus, social phobia does not seem to be uncommon among children displaying anxiety related problems

17. Case Example
Donna presented to therapy because she reported that she was unable to concentrate at home, at school, and with friends. She indicated that she had difficulty falling asleep at night because her mind was “constantly racing” with thoughts and concerns about anything and everything. She described feeling constantly tense and uptight, noting significant difficulty in just being able to enjoy a relaxing activity, like reading or watching TV.

18. Generalized Anxiety Disorder
Excessive anxiety, unrealistic worries, and fearfulness, not related to a specific object or situation
Child finds it difficult to control worry
Plus one of the following symptoms
Restlessness or feeling keyed up/on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance

19. GAD “What if?” statements
Marked degree of subjective distress and excessive worry about a things including:
the appropriateness of past behavior
possible injury or illnesses (to themselves or others),
the possibility of major calamitous events
their ability to live up to expectations
their competencies in various areas
being accepted by others
other things related to concerns about the future

20. GAD: Clinical Characteristics
Children tend to be perfectionistic, worrying about what others will think of them or their performance
Engage in excessive approval seeking and frequent solicitations of reassurance
Anxiety level contributes to physical symptoms:
headaches, dizziness, shortness of breath, upset stomach and problems in sleeping, which may also become a source of concern and worry
Some children also develop "nervous habits" such as nail biting, and hair pulling

21. GAD Prevalence
Strauss (1994), in a review of epidemiological studies, suggests prevalence estimates of 3% to 5% with younger children (< 11 years)
Prevalence rates for adolescents across studies ranged from 4% - 7%
GAD is somewhat more frequently seen in adolescents
No significant gender differences

22. Case Example
The mother of 5-year-old Louisa, says "I go through a routine every night with Louisa. She always makes the same requests when I put her to bed; don't let the bed go up in the sky. Don't let the moon break the house. Don't let any alligators, cows, or snakes into the house.
Scott, age 4, is afraid of the banging of the radiator in his room, the wail of a siren, the noise of thunder.
Serena, age 5, and her mother look under her bed every night to make sure there are no witches hiding there.

23. Childhood Fears and Phobias
Childhood fears are quite common
Lapouse and Monk (l959), in a classic survey of 6 to 12 year‑old children, found that some 43% had 7+ fears
Childhood fears range from those related to very specific and concrete objects (e.g.,animals and strangers) to those which are more abstract (e.g., monsters, war, death).
Some fears seem to be age or stage specific, occurring frequently at certain ages

24. Childhood Fears: Developmental Considerations
Fear of strangers at age 6 to 9 months
Fear of separation at age 1 to 2 years
Fear of the dark at around age 4
Many fears resolve with time and do not require treatment
Some fears are more problematic and the term “phobia” is a more appropriate descriptor of the child's condition.

25. Specific Phobia DSM Criteria
Marked and persistent fear that is excessive and unreasonable, cued by the presence or anticipation of a specific object or situation
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response
Duration of 6 months
Types:
Animal (e.g., snakes)
Natural environment (e.g., storms)
Blood-injection-injury
Situational (e.g., bridges, elevators, flying)
Other (e.g., loud sounds, choking)

26. Childhood Phobias
Miller, Barrett and Hampe (l974) have defined a phobia as a specific type of fear that is:
out of proportion to the demands of the situation
cannot be explained or reasoned away
is beyond voluntary control
leads to avoidance of the feared situation
persists over an extended period of time
is not adaptive
is not age or stage specific

27. Childhood Phobias: Prevalence
Little investigation of the prevalance of these problems in children
2 - 4% in the general child population
Rates on the order of 4% are found for adolescents
Rates as high as 6 - 7% are found in clinical populations

28. Case Example
“Jesse, l0 years old, cleans his teeth so frequently that he uses a box of toothpicks each week and his gums bleed profusely. Each day he uses a half box of Q-tips to clean his ears and a roll of toilet paper when he goes to the toilet. When he does his homework, Jesse can spend an hour on the same page, erasing and rewriting words because he's sure he didn't get them right.”

29. Case Example
“Ashley, l6, reports that each time she leaves a classroom, passes the principal's office or leaves school, she has to imagine the number 12 on a clock and say the words "good luck" to herself. She reports that she can't stop thinking about the words "good luck." If she tries to stop herself from thinking about these words, she becomes very anxious and worries that she'll have a heart attack. In the classroom, she is often frozen in her seat, unable to respond. She worries that any decision she makes will result in something dreadful happening to her parents. Before going to sleep, she closes the bedroom door four times, turns the lights on and off four times and looks out the window and under her bed twelve times.”

30. Obsessive-Compulsive Disorder DSM Criteria
DSM IV Criteria
Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
The thoughts, impulses, or images are not simply excessive worries about real-life problems
The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

31. Obsessive-Compulsive Disorder DSM Criteria
Compulsions as defined by (1) and (2):
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

32. Obsessive-Compulsive Disorder DSM Criteria
B.  At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C.  The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
D.  If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it.
E.  The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

33. Common Obsessions and Compulsions
Contamination
Harm to self or others
Need for symmetry/order
Religious or moral concerns
Sexual or aggressive
Lucky or unlucky numbers
Compulsions
Cleaning
Checking, counting, repeating
Ordering, straightening
Praying, confessing, reassurance seeking
Touching, tapping, or rubbing
Hoarding
The most common obsessive themes in the pediatric population include fears of contamination (e.g., dirt, germs, toxins); preoccupations about harm to self or others; the need for symmetry, exactness, and order; concerns with religious or moral conduct (e.g., being concerned with committing a sin); lucky or unlucky numbers, and preoccupations concerning forbidden sexual or aggressive thoughts (Masi et al., 2005; Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). The most common compulsive themes include cleaning or decontamination rituals (e.g., excessive washing, bathing, or grooming); checking, counting, repeating, straightening, and routinized behaviors (e.g., doors, locks, homework, appliances); confessing, praying, and reassurance seeking; touching, tapping, and rubbing; measures to prevent harm to self or others; and hoarding and collecting

34. OCD: Prevalence and Course
1-4% of children and adolescents
Ratio of boys to girls is 2:1 in childhood; equalizes in adolescence
80% of all cases have childhood onset
Course
Age of onset
Males years (peak 10); Females years
Onset typically gradual, some acute
Chronic waxing and waning of symptoms
Stress exacerbates symptoms
Estimated that 15% display progressive deterioration in social & occupational functioning

35. Case Example
Dylan, 4 years old, presented to treatment because his parents were concerned with his behavior following a incident in which he was attacked by a dog. According to his parents, Dylan would use his toys to reproduce the incident in play. Additionally, Dylan avoided going anywhere near his neighbor’s house (where the dog attack occurred) and became noticeably startled and very distressed when hearing dog barking. For the past several weeks, he had experienced several nightmares in which he dreamt of the dog attack.

36. Post-traumatic Stress Disorder DSM Criteria
A. Exposure
Person exposed to a event that involved threat of harm/death to self or other
Person’s response involved intense fear, helplessness, or horror
B. Traumatic event is re-experienced (1+)
Recurrent and intrusive recollections (play)
Recurrent and distressing dreams
Acting or feeling as if event were recurring (reenactment)
Intense distress at exposure to internal or external cues that resemble an aspect of the event
Physiological reactivity on exposure to cues

37. PTSD DSM Criteria
C. Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness (3+)
Efforts to avoid thoughts/feelings about event
Efforts to avoid activities, places, people related to event
Inability to recall an important aspect of trauma
Markedly diminished interest or participation
Feeling of detachment from others
Restricted range of affect
Sense of foreshortened future

38. PTSD DSM Criteria D. Persistent symptoms of increased arousal (2+)
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
E. Duration of symptoms > 1 month

39. Associated Characteristics of Anxiety Disorders
Cognitive disturbances
Interference with academic performance
Attentional biases (toward threat)
Cognitive biases (negative spin on ambiguous situations)
Physical symptoms
Sleep
Aches/pains
Social and emotional deficits
Interference
Low self-esteem
Loneliness

40. Etiology
Anxiety arises from a complex interaction of specific characteristics related to the child (e.g., biological, psychological, and genetic factors) and his or her environment (e.g., conditioning, observational learning, family relations, traumatic events)
Focus on four most recognized models
Biological
Behavioral
Cognitive
Ecological

41. Etiology Biological Genetic Influences Neurobiological factors
Biological vulnerability to inherit a fearful disposition
Genetic influences account for 1/3 of variance
Neurobiological factors
Within the limbic system, the behavioral inhibition system is overactive
Increased tendency to become over-reactive and withdraw in response to novel stimulation
Irritable, shy, cautious, and quiet temperament

42. Etiology Biology, continued Neurochemical factors
Abnormal function of serotonin, norepinephrine, dopamine, and GABA

43. Etiology Behavioral Mowrer’s Two Stage Model of Conditioning
Acquisition of fear through classical conditioning
An individual associates a threatening stimulus with a nonthreatening stimulus, so that the latter by itself triggers anxiety
Maintenance of fear through operant conditioning
Negative reinforcement is manifested by avoidance and/or escape learning
Consequently, without opportunities for new learning provided by exposure, the fear/anxiety does not extinguish

44. Etiology Behavioral, continued Observational learning
Children learn about anxiety-provoking situations by
observing others experience such situations or
by acquiring information through activities like reading or watching the news on television

45. Etiology
Cognitive
Attentional biases toward threat-related information
Selectively attend to information that may be potentially threatening
Distorted judgments of risk
Negative spin on ambiguous/non-threatening situations
Lead them to select avoidant solutions
Selective memory processing
Tendency to remember anxiety-provoking cues/experiences
Perfectionistic beliefs
Inflated sense of responsibility

46. Etiology
Ecological
Bidirectional relationships among child, family, and other environmental contributions to anxiety
Child temperamental characteristics (i.e., behavioral inhibition) X insecure parent-child attachment X anxious and controlling parenting styles
Parental modeling of fear responses
Community violence

47. Assessment Diagnostic Interviews
Anxiety Disorders Interview Schedule for DSM-IV
Schedule for Affective Disorders and Schizophrenia for School-Age Children
Clinician-administered
Comprehensive
Time-consuming and labor-intensive

48. Assessment Rating Scales
Screen for Child Anxiety Related Emotional Disorders - Revised (SCARED)
Multidimensional Anxiety Scale for Children
Fear Survey Schedule for Children – Revised
Also, disorder-specific measures
Quick and easy to administer
Standardized with good psychometric properties
Can be used as screening devices *not to diagnose

49. Assessment Observation Self-monitoring procedures
Social-evaluative tasks (e.g., classroom presentation)
Behavioral avoidance to phobic stimulus
Parent-child interaction
Self-monitoring procedures
Quantify and describe symptoms

50. Treatment
Behavioral and Cognitive-Behavioral Treatments have received most empirical support
Pharmacotherapy has recently received promising support
Selective Serotonin Reuptake Inhibitors (SSRIs)
Psychodynamic and Family therapies have not received much empirical support

51. Treatment Treatments should target the 3 interrelated symptoms
Physical symptoms
Rapid heart beat
Muscle tension
Insomnia
Cognitive symptoms
Distorted perceptions of threat
Behavioral symptoms
Avoidance
Escape

52. Behavioral Therapy Exposure Therapy Systematic Desensitization
Relaxation Exercises
Contingency Management Strategies
Modeling

53. Exposure Create fear hierarchy
List of fearful events, rated on scale from least to most anxiety-provoking
Example: Fear of snakes
Talk about snakes 3
See pictures of snakes 5
Watch movies of snakes 6
Touch a rubber snake 8
Go to pet store and hold snake 10
Gradual exposure: Child confronts fear

54. Exposure with Response Prevention
Obsessive-compulsive disorder
In addition to exposures, the child is asked to refrain from engaging in compulsive rituals
Example
Touches floor of public bathroom (exposure)
Does not engage in handwashing (response prevention)
Proposed therapeutic mechanism of exposure
Break the conditioned fear response
Consequently, acquire new, less threatening (and more adaptive), fear representations

55. Systematic Desensitization
3 Steps
Teach child to relax
Construct fear hierarchy
Present anxiety-provoking stimuli sequentially as child remains relaxed
Proposed therapeutic mechanism
Break the conditioned fear response, because relaxation is incompatible with fear response
Which is better???

56. Relaxation Deep breathing Imagery Progressive Muscle Relaxation
Proposed therapeutic mechanism
Increased control over sympathetic nervous system
Decreased physiological symptoms

57. Reinforced Practice
Reinforced Practice: in vivo exposure with a feared situation or object and rewards (e.g. praise, tokens, toys, hugs, etc.) for approaching and confronting a feared situation or object

58. Modeling
Filmed modeling
Live modeling
Participant modeling

59. Cognitive-Behavioral Therapy
In addition to behavioral strategies…
Teaches children to understand how thoughts contribute to anxiety
And how to modify distorted thoughts to decrease symptoms
FEELINGS
BEHAVIOR
THOUGHTS

60. Cognitive-Behavioral Therapy
Components
Psychoeducation about nature of symptoms
Skill building
Cognitive restructuring
Positive self-talk
Problem solving
Approach-oriented coping
Relaxation strategies
Exposure
Role play
Contingency reinforcement: rewards

61. Coping Cat: CBT for Anxiety
Developed by Phil Kendall at Temple University
It is based on basic Cognitive Behavioral Principles
Treatment typically takes place across 16 sessions where the child is taught:
how to recognize their physical reactions and anxious feelings when confronted with anxiety related stimuli
to become aware of anxiety-related cognitions
to develop a coping plan for dealing with anxiety that involves positive self statements and problem solving skills

62. Coping Cat
The child is also taught to evaluate their coping responses and apply self-reinforcement for adaptive coping behaviors
Children are encouraged to engage in both imaginal and in vivo exposure to anxiety related stimuli, while using the skills they have been taught
In-session and out-of-session activities are used to give children opportunities to use skills
Therapists also reinforce the successful use of coping skills

63. SAD Behavioral components: Cognitive components:
Extra targets: School refusal

64. Social Phobia Behavioral components: Cognitive components:
Extra targets: Social Skills Training

65. Generalized Anxiety Disorder
Behavioral components
Cognitive components
Extra targets: Reassurance seeking

66. Specific Phobia
Behavioral components
Mostly transient conditions

67. OCD Behavioral components: Cognitive components:
Extra Targets: Medications
SSRIs: Luvox, Paxil, Prozac, and Zoloft
Majority of children on medication improve, but may relapse and need further treatment.

68. PTSD Trauma-focused CBT psychoeducation and parenting skills
relaxation
affective modulation: identifying and coping with negative emotions
cognitive strategies
trauma narrative
in vivo mastery of trauma reminders
conjoint child-parent sessions
enhancing future safety and development

69. Any Questions