Transcript Child Anxiety Disorders

Childhood
Anxiety
Disorders
Anxiety
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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
Developmental
Considerations
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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
Developmental
Considerations
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DSM-IV qualifiers for children
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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
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Internalizing symptoms less observable
Internalizing symptoms less aversive
Children may lack verbal skills to
communicate concerns
Anxiety: 3 Interrelated
Systems
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Cognitive
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Physical
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Anxious thoughts develop in response to
cognitive distortions in the attention,
interpretation, and memory components of
information processing
Brain sends messages to sympathetic
nervous system: fight or flight response
Symptoms are excessive in intensity or
duration
Behavioral
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Action (or inaction) that individuals
take to prevent exposure to feared
stimuli or to reduce anxiety associated
Case Example
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“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
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Separation Anxiety
Disorder DSM Criteria:
3+
symptoms
Excessive distress
Excessive fear or
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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
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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
SAD:
Clinical Presentation
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Demand parental attention
Clinging
Sleep with parents
Prevalence, Age of Onset,
Family Characteristics
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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
Case Example
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“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
Social Phobia
DSM Criteria
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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
Social Phobia:
Clinical Features
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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
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Social Phobia:
Clinical Features
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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
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In older children, it may be
expressed less dramatically in
terms of trembling hands, a shaky
voice or other obvious signs of
Social Phobia:
Clinical Features
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Children with social
phobias also experience
anticipatory anxiety
well before actually
confronting these
situation
Unfortunate cycle
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Anticipate
awkwardness/poor
performance
Increased anxiety
Actual awkwardness/poor
performance
Social Phobia:
Associated Features
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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
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School performance may be
impaired due to test anxiety and
failure to participate in
classroom activities
Social Phobia:
Prevalence
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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
Case Example
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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
Generalized Anxiety
Disorder
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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
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Restlessness or feeling keyed up/on edge
Being easily fatigued
Difficulty concentrating or mind going
blank
Irritability
Muscle tension
Sleep disturbance
GAD
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“What if?” statements
Marked degree of subjective distress
and excessive worry about a things
including:
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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
GAD: Clinical
Characteristics
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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:
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headaches, dizziness, shortness of
breath, upset stomach and problems in
sleeping, which may also become a source
of concern and worry
GAD Prevalence
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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
Case Example
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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.
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Scott, age 4, is afraid of the
banging of the radiator in his room,
the wail of a siren, the noise of
thunder.
Childhood Fears and
Phobias
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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).
Childhood Fears:
Developmental Considerations
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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
Specific Phobia
DSM Criteria
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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:
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Animal (e.g., snakes)
Natural environment (e.g., storms)
Blood-injection-injury
Situational (e.g., bridges, elevators, flying)
Childhood Phobias
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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
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Childhood Phobias:
Prevalence
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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
Case Example
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“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
Case Example
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“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
Obsessive-Compulsive Disorder
DSM Criteria
DSM IV Criteria
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and
(4):
1. 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
2. The thoughts, impulses, or images are not
simply excessive worries about real-life
problems
3. The person attempts to ignore or suppress
such thoughts, impulses, or images, or to
neutralize them with some other thought or
action
4. The person recognizes that the obsessional
Obsessive-Compulsive Disorder
DSM Criteria
Compulsions as defined by (1) and (2):
1. 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
2. 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
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.
Common Obsessions and
Compulsions
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Obsessions
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Contamination
Harm to self or
others
Need for
symmetry/order
Religious or
moral concerns
Sexual or
aggressive
Lucky or unlucky
numbers
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Compulsions
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Cleaning
Checking,
counting,
repeating
Ordering,
straightening
Praying,
confessing,
reassurance
seeking
Touching,
tapping, or
OCD: Prevalence and Course
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Prevalence
 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 6 - 15 years (peak 10); Females
20 - 29 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
Case Example
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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
Post-traumatic Stress Disorder
DSM Criteria
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A. Exposure
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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+)
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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
PTSD
DSM Criteria
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C. Persistent avoidance of stimuli
associated with trauma and numbing
of general responsiveness (3+)
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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
PTSD
DSM Criteria
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D. Persistent symptoms of
increased arousal (2+)
Difficulty falling or staying
asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response
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E. Duration of symptoms > 1
month
Associated Characteristics
of Anxiety Disorders
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Cognitive disturbances
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Physical symptoms
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Interference with academic performance
Attentional biases (toward threat)
Cognitive biases (negative spin on
ambiguous situations)
Sleep
Aches/pains
Social and emotional deficits
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Interference
Low self-esteem
Loneliness
Etiology
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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
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Biological
Behavioral
Cognitive
Etiology
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Biological
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Genetic Influences
Biological vulnerability to inherit a
fearful disposition
 Genetic influences account for 1/3 of
variance
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Neurobiological factors
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Within the limbic system, the
behavioral inhibition system is
overactive
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Increased tendency to become over-reactive
and withdraw in response to novel
stimulation
Etiology
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Biology, continued
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Neurochemical factors
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Abnormal function of serotonin,
norepinephrine, dopamine, and GABA
Etiology
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Behavioral
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Mowrer’s Two Stage Model of
Conditioning
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Acquisition of fear through classical
conditioning
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An individual associates a threatening
stimulus with a nonthreatening stimulus,
so that the latter by itself triggers
anxiety
Maintenance of fear through operant
conditioning
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Negative reinforcement is manifested by
avoidance and/or escape learning
Etiology
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Behavioral, continued
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Observational learning
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Children learn about anxietyprovoking situations by
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observing others experience such
situations or
by acquiring information through
activities like reading or watching the
news on television
Etiology
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Cognitive
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Attentional biases toward threat-related
information
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Distorted judgments of risk
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Negative spin on ambiguous/non-threatening
situations
Lead them to select avoidant solutions
Selective memory processing
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Selectively attend to information that may be
potentially threatening
Tendency to remember anxiety-provoking
cues/experiences
Perfectionistic beliefs
Etiology
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Ecological
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Bidirectional relationships among
child, family, and other
environmental contributions to
anxiety
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Child temperamental characteristics
(i.e., behavioral inhibition) X
insecure parent-child attachment X
anxious and controlling parenting
styles
Parental modeling of fear
responses
Assessment
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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
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Assessment
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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
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Assessment
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Observation
Social-evaluative tasks (e.g.,
classroom presentation)
 Behavioral avoidance to phobic
stimulus
 Parent-child interaction
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Self-monitoring procedures
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Quantify and describe symptoms
Treatment
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Behavioral and CognitiveBehavioral Treatments have
received most empirical support
Pharmacotherapy has recently
received promising support
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Selective Serotonin Reuptake
Inhibitors (SSRIs)
Psychodynamic and Family
therapies have not received
much empirical support
Treatment
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Treatments should target the 3
interrelated symptoms
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Physical symptoms
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Cognitive symptoms
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Rapid heart beat
Muscle tension
Insomnia
Distorted perceptions of threat
Behavioral symptoms
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Avoidance
Escape
Behavioral Therapy
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Exposure Therapy
Systematic Desensitization
Relaxation Exercises
Contingency Management
Strategies
Modeling
Exposure
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Create fear hierarchy
List of fearful events, rated on
0-100 scale from least to most
anxiety-provoking
 Example: Fear of snakes
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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
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10
Gradual exposure: Child confronts
fear
Exposure with Response
Prevention
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Obsessive-compulsive disorder
In addition to exposures, the
child is asked to refrain from
engaging in compulsive rituals
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Touches floor of public bathroom
(exposure)
 Does not engage in handwashing
(response prevention)
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Proposed therapeutic mechanism
of exposure
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Break the conditioned fear
Systematic
Desensitization
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3 Steps
Teach child to relax
 Construct fear hierarchy
 Present anxiety-provoking stimuli
sequentially as child remains
relaxed
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Proposed therapeutic mechanism
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Break the conditioned fear
response, because relaxation is
incompatible with fear response
Which is better???
Relaxation
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Deep breathing
Imagery
Progressive Muscle Relaxation
Proposed therapeutic mechanism
Increased control over sympathetic
nervous system
 Decreased physiological symptoms
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Reinforced Practice
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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
Modeling
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Filmed modeling
Live modeling
Participant modeling
Cognitive-Behavioral
Therapy
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In addition to behavioral
strategies…
Teaches children to understand
how thoughts contribute to
anxiety
And how toFEELINGS
modify distorted
thoughts to decrease symptoms
THOUGHTS
BEHAVIOR
Cognitive-Behavioral
Therapy
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Components
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Psychoeducation about nature of symptoms
Skill building
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Cognitive restructuring
Positive self-talk
Problem solving
Approach-oriented coping
Relaxation strategies
Exposure
Role play
Contingency reinforcement: rewards
Coping Cat: CBT for Anxiety
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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:
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how to recognize their physical reactions
and anxious feelings when confronted with
anxiety related stimuli
to become aware of anxiety-related
Coping Cat
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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
SAD
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Behavioral components:
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Cognitive components:
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Extra targets: School refusal
Social Phobia
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Behavioral components:
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Cognitive components:
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Extra targets: Social Skills
Training
Generalized Anxiety
Disorder
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Behavioral components
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Cognitive components
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Extra targets: Reassurance
seeking
Specific Phobia
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Behavioral components
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Mostly transient conditions
OCD
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Behavioral components:
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Cognitive components:
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Extra Targets: Medications
 SSRIs: Luvox, Paxil, Prozac, and
Zoloft
 Majority of children on medication
PTSD
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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
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Any Questions