1. Kimberly Becker, Ph.D. Johns Hopkins Child and Adolescent Psychiatry

2. Objectives Gain knowledge about the prevalence and course of child anxiety Understand how to recognize symptoms and manifestations of anxiety Learn how CBT addresses anxiety symptoms

3. Facts about Anxiety Disorders Prevalence of anxiety disorder: 10%, but often unidentified and misdiagnosed Mean age of onset: 7-15 years old Impairment: academics, attendance, peers, families Course: Waxes and wanes 1/3 of kids with anxiety improve without treatment Most adult anxiety disorders have pediatric onset Comorbidity: very common

4. Comorbidity Having more than one disorder Additional anxiety disorder: 30-80% Mood disorder: 12-60% Externalizing disorder (ADHD, CD, ODD): 3-60%

5. Symptoms of Anxiety Physical Feelings ThoughtsBehaviors

6. Physical Feelings Muscle tension Heart palpitations Abdominal pain Nausea Flushed face Headaches Perspiration Anxious youth EXPERIENCE more physical difficulties/complaints Anxious youth are MORE SENSITIVE to physical sensations I have a headache and stomachache. Teacher, can I go see the nurse?

7. Thoughts Catastrophizing: blowing things out of proportion Overestimating: expecting the worst will happen “What if…??” What if the teacher calls on me? I always get the answer wrong!

8. Behavior Avoidance/escape Reassurance-seeking Tantrums/disruptive behavior/school refusal

9. Is anxiety good or bad? Excessive Persistent Developmentally inappropriate Results in accommodation by others Causes impairment When is anxiety a problem? Anxiety is normal and adaptive. It serves as a natural alarm system to alert us to danger.

10. Evidence-based Assessment Multiple informants (e.g., child, parent, teachers, clinicians, etc.) Multiple methods Questionnaires Interviews (e.g., ADIS-IV-C) Behavioral observation Repeated, ongoing assessment throughout treatment Frequency, duration, intensity, interference

11. Evidence-Based Treatments for Anxiety Disorders in Children Medication (SSRIs) Cognitive Behavioral Therapy (CBT) Child Anxiety Multisite Study (CAMS) Medication effective CBT effective Combination most effective

12. Empirical Evidence Summary > 20 controlled trials Response: CBT 55-80% Treatment gains maintained – 5-7 years Parent symptoms = poorer outcomes

13. Goals of CBT for Anxiety Reduce anxiety, but not eliminate it Increase ability to manage and cope with anxiety by teaching skills Identify and change anxious behaviors (avoidance) and thoughts

14. Physical Symptoms Relaxation Skills Thoughts Anxious to Coping Thoughts Behaviors Problem Solving Skills, Exposure/Practice Rewards Anxiety Symptoms and CBT Skills Psychoeducation

15. Goal: To provide basic facts about anxiety and its treatment, instill hope When: Session 1, and thereafter Key Points: Define anxiety: find common language Normalize anxiety: everyone experiences it sometimes Externalize anxiety: it is a reaction to situations…an alarm (true alarm vs. false alarm) Propose treatment: (1) CBT model, (2) How do you know the difference between true alarm and false alarm? Test it out!

16. Exposure/Practice: Facing Fears The key component of CBT for anxiety Rationale Anxiety is partly learned and can be unlearned Learn that feared consequences do not occur Fear Ladder Gradually build from easy to hard situations to practice Step 1 Step 2 Step 3 Step 4 Step 5 Goal!

17. Sample Fear Hierarchy SituationRating Giving speech in front of class10 Giving answer aloud in class 8 Asking question aloud in class 6 Writing on blackboard in class 4 Throwing trash away in class 2

18. Item Selection Start exposure/practice by collaboratively choosing an item that the child will not refuse and that the child will successfully complete Move up the ladder as the child masters each item A “good item” is one that provokes anxiety and that the child habituates or gets used to over time Be creative!

20. Summary Anxiety : Normal and adaptive Affects: thoughts, feelings, behaviors Anxiety disorders are: Common Misidentified and under-treated Amenable to treatment CBT is: Time-limited Skill-based Effective for treating anxiety (50-80% improvement rate)

21. Additional Resources ABCT. ORG ACADEMYOFCT.ORG ADAA.ORG: convention March 2010, Baltimore Chorpita, B. F. (2007). Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders. NY: Guilford. DuPont Spencer, E. DuPont, R., & DuPont, C. (2003). The Anxiety Cure for Kids. New Jersey: Wiley. Manassis, K. (1996). Keys to Parenting Your Anxious Child. Hauppauge, NY: Barron’s Education Series. Rapee, R. M., Spence, S. H., Cobham, V., & Wignall, A. (2000). Helping Your Anxious Child. Oakland: New Harbinger Press.