Childhood Childhood Anxiety Anxiety DisordersDisorders

AnxietyAnxiety

Anxiety: mood state Anxiety: mood state characterized by strong, characterized by strong, negative emotion and bodily negative emotion and bodily symptoms in which an individual symptoms in which an individual apprehensively anticipates apprehensively anticipates future danger or misfortunefuture danger or misfortune

Fear: immediate alarm reaction Fear: immediate alarm reaction to current dangerto current danger

Anxiety disorder: Anxiety disorder: excessiveexcessive and and debilitating debilitating anxiety with anxiety with negative emotion and fearnegative emotion and fear

Developmental Developmental ConsiderationsConsiderations

Anxiety is an adaptive emotion Anxiety is an adaptive emotion that readies children both that readies children both physically and psychologically physically and psychologically to cope with dangerto cope with danger

InfancyInfancy: loud noises, being : loud noises, being startled, strangersstartled, strangers

ToddlerhoodToddlerhood: dark, separation: dark, separation School-AgeSchool-Age: injury, natural : injury, natural disastersdisasters

AdolescenceAdolescence: competency-based : competency-based concerns, health of self and concerns, health of self and othersothers

Developmental Developmental ConsiderationsConsiderations

DSM-IV qualifiers for childrenDSM-IV qualifiers for children Anxiety may be expressed by crying, Anxiety may be expressed by crying, tantrums, freezing, or clingingtantrums, freezing, or clinging

Unlike adults, children are not Unlike adults, children are not required to acknowledge that fears are required to acknowledge that fears are unreasonable or excessiveunreasonable or excessive

Difficulties in recognizing symptomsDifficulties in recognizing symptoms Internalizing symptoms less observableInternalizing symptoms less observable Internalizing symptoms less aversiveInternalizing symptoms less aversive Children may lack verbal skills to Children may lack verbal skills to communicate concernscommunicate concerns

Anxiety: 3 Interrelated Anxiety: 3 Interrelated SystemsSystems

CognitiveCognitive Anxious thoughts develop in response to Anxious thoughts develop in response to cognitive distortions in the attention, cognitive distortions in the attention, interpretation, and memory components interpretation, and memory components of information processingof information processing

PhysicalPhysical Brain sends messages to sympathetic Brain sends messages to sympathetic nervous system: fight or flight nervous system: fight or flight responseresponse

Symptoms are excessive in intensity or Symptoms are excessive in intensity or durationduration

BehavioralBehavioral Action (or inaction) that individuals Action (or inaction) that individuals take to prevent exposure to feared take to prevent exposure to feared stimuli or to reduce anxiety associated stimuli or to reduce anxiety associated with exposure to the feared stimuliwith exposure to the feared stimuli

Case ExampleCase Example

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

Separation Anxiety Separation Anxiety Disorder DSM Criteria: Disorder DSM Criteria:

3+ symptoms3+ symptoms Excessive distress Excessive distress

when separation when separation from attachment from attachment figure is figure is anticipatedanticipated

Excessive worry Excessive worry about losing or about losing or possible harm to possible harm to figurefigure

Excessive worry Excessive worry that an event will that an event will lead to separationlead to separation

Reluctance or Reluctance or refusal to go to refusal to go to school because of school because of separation fearseparation fear

Excessive fear or Excessive fear or reluctance to be reluctance to be alonealone

Reluctance or Reluctance or refusal to go to refusal to go to sleep without being sleep without being near attachment near attachment figurefigure

Nightmares Nightmares involving theme of involving theme of separationseparation

Complaints of Complaints of physical symptoms physical symptoms when separation when separation occurs/is occurs/is anticipatedanticipated

SAD: SAD: Clinical PresentationClinical Presentation

Demand parental attentionDemand parental attention ClingingClinging Sleep with parentsSleep with parents

Prevalence, Age of Onset, Prevalence, Age of Onset, Family CharacteristicsFamily Characteristics

Prevalence rate of 2 - 4%Prevalence rate of 2 - 4% SAD accounts for 1/2 of all SAD accounts for 1/2 of all children and adolescents referred children and adolescents referred for treatment of anxiety for treatment of anxiety disorders disorders

Occurs as early as preschool age Occurs as early as preschool age No gender differencesNo gender differences Often occurs in response to some Often occurs in response to some major stressormajor stressor

Case ExampleCase Example

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

Social PhobiaSocial PhobiaDSM CriteriaDSM Criteria

Marked and persistent fear of one or Marked and persistent fear of one or more social or performance more social or performance situations in which child is exposed situations in which child is exposed to unfamiliar people or possible to unfamiliar people or possible scrutiny by othersscrutiny by others

The child fears he/she will act in a The child fears he/she will act in a way that will be humiliating or way that will be humiliating or embarrassingembarrassing

Exposure to situation provokes Exposure to situation provokes considerable anxietyconsiderable anxiety

Feared situations are avoided or Feared situations are avoided or else endured with intense anxiety else endured with intense anxiety and distressand distress

Social Phobia: Social Phobia: Clinical FeaturesClinical Features

A child with social phobia is A child with social phobia is one who displays phobic one who displays phobic responses to one or more social responses to one or more social situations:situations: Speaking, eating, or drinking in Speaking, eating, or drinking in front of othersfront of others

Initiating or maintaining Initiating or maintaining conversationsconversations

Speaking to adult authority figuresSpeaking to adult authority figures Other situations that may elicit Other situations that may elicit concerns over concerns over being being embarrassed/humiliatedembarrassed/humiliated

Social Phobia: Social Phobia: Clinical FeaturesClinical Features

In young childrenIn young children, the anxiety , the anxiety may be reflected in signs of may be reflected in signs of distress such as crying, throwing distress such as crying, throwing temper tantrums, or becoming mute temper tantrums, or becoming mute and clinging to parentsand clinging to parents

In older children,In older children, it may be it may be expressed less dramatically in expressed less dramatically in terms of trembling hands, a shaky terms of trembling hands, a shaky voice or other obvious signs of voice or other obvious signs of anxiety anxiety

Social Phobia: Social Phobia: Clinical FeaturesClinical Features

Children with social Children with social phobias also experience phobias also experience anticipatory anxietyanticipatory anxiety well before actually well before actually confronting these confronting these situationsituation

Unfortunate cycleUnfortunate cycle Anticipate Anticipate awkwardness/poor awkwardness/poor performanceperformance

Increased anxietyIncreased anxiety Actual awkwardness/poor Actual awkwardness/poor performanceperformance

Can interfere with the Can interfere with the child's ability to function child's ability to function in a wide range of areasin a wide range of areas

Social Phobia: Social Phobia: Associated FeaturesAssociated Features

Children with social phobias can Children with social phobias can also show a range of also show a range of associated associated features:features: Being overly sensitive to Being overly sensitive to criticismcriticism

Having low levels of self-esteem Having low levels of self-esteem Having inadequate social skills Having inadequate social skills

School performance may be School performance may be impaired due to test anxiety and impaired due to test anxiety and failure to participate in failure to participate in classroom activities classroom activities

Social anxieties can result in Social anxieties can result in school refusalschool refusal

Social Phobia: Social Phobia: PrevalencePrevalence

Relatively rare in the general child Relatively rare in the general child populationpopulation

Prevalence estimates of around 1-3% Prevalence estimates of around 1-3% are suggested by cross-sectional are suggested by cross-sectional researchresearch

No gender differencesNo gender differences Last, et al. (1992) has suggested Last, et al. (1992) has suggested that among children referred to an that among children referred to an anxiety disorders clinic, 20% met DSM anxiety disorders clinic, 20% met DSM criteria for a diagnosis of social criteria for a diagnosis of social phobiaphobia

Thus, social phobia does not seem to Thus, social phobia does not seem to be uncommon among children displaying be uncommon among children displaying anxiety related problems anxiety related problems

Case ExampleCase Example

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

Generalized Anxiety Generalized Anxiety DisorderDisorder

Excessive anxiety, unrealistic Excessive anxiety, unrealistic worries, and fearfulnessworries, and fearfulness, not , not related to a specific object or related to a specific object or situationsituation

Child finds it difficult to control Child finds it difficult to control worryworry

Plus one of the following symptomsPlus one of the following symptoms Restlessness or feeling keyed up/on edgeRestlessness or feeling keyed up/on edge Being easily fatiguedBeing easily fatigued Difficulty concentrating or mind going Difficulty concentrating or mind going blankblank

IrritabilityIrritability Muscle tensionMuscle tension Sleep disturbanceSleep disturbance

GADGAD

““What if?” statementsWhat if?” statements Marked degree of subjective distress Marked degree of subjective distress and excessive worry about a things and excessive worry about a things including:including: the appropriateness of past behaviorthe appropriateness of past behavior possible injury or illnesses (to possible injury or illnesses (to themselves or others),themselves or others),

the possibility of major calamitous the possibility of major calamitous eventsevents

their ability to live up to their ability to live up to expectations expectations

their competencies in various areastheir competencies in various areas being accepted by others being accepted by others other things related to concerns about other things related to concerns about the futurethe future

GAD: Clinical GAD: Clinical CharacteristicsCharacteristics

Children tend to be Children tend to be perfectionisticperfectionistic, , worrying about what others will think worrying about what others will think of them or their performanceof them or their performance

Engage in Engage in excessive approval seekingexcessive approval seeking and and frequent solicitations of frequent solicitations of reassurancereassurance

Anxiety level contributes to Anxiety level contributes to physical physical symptomssymptoms:: headaches, dizziness, shortness of headaches, dizziness, shortness of breath, upset stomach and problems in breath, upset stomach and problems in sleeping, which may also become a source sleeping, which may also become a source of concern and worryof concern and worry

Some children also develop "Some children also develop "nervous nervous habitshabits" such as nail biting, and hair " such as nail biting, and hair pullingpulling

GAD PrevalenceGAD Prevalence

Strauss (1994), in a review of Strauss (1994), in a review of epidemiological studies, suggests epidemiological studies, suggests prevalence estimates of 3% to 5% prevalence estimates of 3% to 5% with younger children (< 11 with younger children (< 11 years)years)

Prevalence rates for adolescents Prevalence rates for adolescents across studies ranged from 4% - across studies ranged from 4% - 7%7%

GAD is somewhat more frequently GAD is somewhat more frequently seen in adolescentsseen in adolescents

No significant gender differencesNo significant gender differences

Case ExampleCase Example

The mother of 5-year-old Louisa, The mother of 5-year-old Louisa, says "I go through a routine every says "I go through a routine every night with Louisa. She always makes night with Louisa. She always makes the same requests when I put her to the same requests when I put her to bed; don't let the bed go up in the bed; don't let the bed go up in the sky. Don't let the moon break the sky. Don't let the moon break the house. Don't let any alligators, house. Don't let any alligators, cows, or snakes into the house. cows, or snakes into the house.

Scott, age 4, is afraid of the Scott, age 4, is afraid of the banging of the radiator in his room, banging of the radiator in his room, the wail of a siren, the noise of the wail of a siren, the noise of thunder.thunder.

Serena, age 5, and her mother look Serena, age 5, and her mother look under her bed every night to make under her bed every night to make sure there are no witches hiding sure there are no witches hiding there.there.

Childhood Fears and Childhood Fears and Phobias Phobias

Childhood fears are Childhood fears are quite common quite common

Lapouse and Monk (l959Lapouse and Monk (l959), ), in a classic survey of 6 in a classic survey of 6 to 12 year old children, ‑to 12 year old children, ‑found that some 43% had found that some 43% had 7+ fears 7+ fears

Childhood fears range Childhood fears range from those related to from those related to very very specific and specific and concreteconcrete objects objects (e.g.,animals and (e.g.,animals and strangers) to those strangers) to those which are more which are more abstractabstract (e.g., monsters, war, (e.g., monsters, war, death). death).

Some fears seem to be Some fears seem to be age or stage specificage or stage specific, , occurring frequently at occurring frequently at certain agescertain ages

Childhood Fears:Childhood Fears:Developmental ConsiderationsDevelopmental Considerations

Fear of strangers at age 6 to Fear of strangers at age 6 to 9 months 9 months

Fear of separation at age 1 Fear of separation at age 1 to 2 yearsto 2 years

Fear of the dark at around Fear of the dark at around age 4age 4

Many fears resolve with time Many fears resolve with time and do not require treatment and do not require treatment

Some fears are more Some fears are more problematic and the term problematic and the term “phobia” is a more “phobia” is a more appropriate descriptor of the appropriate descriptor of the child's condition. child's condition.

Specific PhobiaSpecific PhobiaDSM CriteriaDSM Criteria

Marked and persistent fear that is Marked and persistent fear that is excessive and unreasonable, cued by excessive and unreasonable, cued by the presence or anticipation of a the presence or anticipation of a specific object or situationspecific object or situation

Exposure to the phobic stimulus Exposure to the phobic stimulus almost invariably provokes an almost invariably provokes an immediate anxiety responseimmediate anxiety response

Duration of 6 monthsDuration of 6 months Types:Types:

Animal (e.g., snakes)Animal (e.g., snakes) Natural environment (e.g., storms)Natural environment (e.g., storms) Blood-injection-injury Blood-injection-injury Situational (e.g., bridges, elevators, flying)Situational (e.g., bridges, elevators, flying) Other (e.g., loud sounds, choking)Other (e.g., loud sounds, choking)

Childhood PhobiasChildhood Phobias

Miller, Barrett and Hampe (l974) Miller, Barrett and Hampe (l974) have defined a phobia as a have defined a phobia as a specific type of fear that is:specific type of fear that is: out of proportion to the demands out of proportion to the demands of the situation of the situation

cannot be explained or reasoned cannot be explained or reasoned awayaway

is beyond voluntary control is beyond voluntary control leads to avoidance of the feared leads to avoidance of the feared situationsituation

persists over an extended period persists over an extended period of timeof time

is not adaptiveis not adaptive is not age or stage specific is not age or stage specific

Childhood Phobias: Childhood Phobias: PrevalencePrevalence

Little investigation of the Little investigation of the prevalance of these prevalance of these problems in childrenproblems in children

2 - 4% in the general child 2 - 4% in the general child population population

Rates on the order of 4% Rates on the order of 4% are found for adolescentsare found for adolescents

Rates as high as 6 - 7% are Rates as high as 6 - 7% are found in clinical found in clinical populations populations

Case ExampleCase Example

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

Case ExampleCase Example

““Ashley, l6Ashley, l6, reports that each time she , reports that each time she leaves a classroom, passes the principal's leaves a classroom, passes the principal's office or leaves school, she has to office or leaves school, she has to imagine the number 12 on a clock and say imagine the number 12 on a clock and say the words "good luck" to herself. She the words "good luck" to herself. She reports that she can't stop thinking about reports that she can't stop thinking about the words "good luck." If she tries to the words "good luck." If she tries to stop herself from thinking about these stop herself from thinking about these words, she becomes very anxious and words, she becomes very anxious and worries that she'll have a heart attack. worries that she'll have a heart attack. In the classroom, she is often frozen in In the classroom, she is often frozen in her seat, unable to respond. She worries her seat, unable to respond. She worries that any decision she makes will result in that any decision she makes will result in something dreadful happening to her something dreadful happening to her parents. Before going to sleep, she closes parents. Before going to sleep, she closes the bedroom door four times, turns the the bedroom door four times, turns the lights on and off four times and looks out lights on and off four times and looks out the window and under her bed twelve the window and under her bed twelve times.”times.”

Obsessive-Compulsive DisorderObsessive-Compulsive DisorderDSM CriteriaDSM Criteria

DSM IV CriteriaDSM IV CriteriaA.A. Either obsessions or compulsions: Either obsessions or compulsions:

Obsessions Obsessions as defined by (1), (2), (3), and (4):as defined by (1), (2), (3), and (4):1.1. Recurrent and persistent thoughts, impulses, Recurrent and persistent thoughts, impulses,

or images that are experienced, at some time or images that are experienced, at some time during the disturbance, as intrusive and during the disturbance, as intrusive and inappropriate and that cause marked anxiety inappropriate and that cause marked anxiety or distress or distress

2.2. The thoughts, impulses, or images are not The thoughts, impulses, or images are not simply excessive worries about real-life simply excessive worries about real-life problems problems

3.3. The person attempts to ignore or suppress The person attempts to ignore or suppress such thoughts, impulses, or images, or to such thoughts, impulses, or images, or to neutralize them with some other thought or neutralize them with some other thought or action action

4.4. The person recognizes that the obsessional The person recognizes that the obsessional thoughts, impulses, or images are a product thoughts, impulses, or images are a product of his or her own mind (not imposed from of his or her own mind (not imposed from without as in thought insertion) without as in thought insertion)

Obsessive-Compulsive DisorderObsessive-Compulsive DisorderDSM CriteriaDSM Criteria

CompulsionsCompulsions as defined by (1) and (2): as defined by (1) and (2):

1.1. Repetitive behaviors (e.g., hand washing, Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., ordering, checking) or mental acts (e.g., praying, counting, repeating words praying, counting, repeating words silently) that the person feels driven to silently) that the person feels driven to perform in response to an obsession, or perform in response to an obsession, or according to rules that must be applied according to rules that must be applied rigidly rigidly

2.2. The behaviors or mental acts are aimed at The behaviors or mental acts are aimed at preventing or reducing distress or preventing or reducing distress or preventing some dreaded event or preventing some dreaded event or situation; however, these behaviors or situation; however, these behaviors or mental acts either are not connected in a mental acts either are not connected in a realistic way with what they are designed realistic way with what they are designed to neutralize or prevent or are clearly to neutralize or prevent or are clearly excessive excessive

Obsessive-Compulsive DisorderObsessive-Compulsive DisorderDSM CriteriaDSM Criteria

B.  At some point during the course of the B.  At some point during the course of the disorder, the person has recognized that disorder, the person has recognized that the obsessions or compulsions are the obsessions or compulsions are excessive or unreasonable. excessive or unreasonable. Note: This does Note: This does not apply to children. not apply to children.

C.  The obsessions or compulsions cause C.  The obsessions or compulsions cause marked distress, are time consuming (take marked distress, are time consuming (take more than 1 hour a day), or significantly more than 1 hour a day), or significantly interfere with the person’s normal interfere with the person’s normal routine, occupational (or academic) routine, occupational (or academic) functioning, or usual social activities or functioning, or usual social activities or relationships. relationships.

D.  If another Axis I disorder is present, D.  If another Axis I disorder is present, the content of the obsessions or the content of the obsessions or compulsions is not restricted to it. compulsions is not restricted to it.

E.  The disturbance is not due to the direct E.  The disturbance is not due to the direct physiological effects of a substance physiological effects of a substance (e.g., a drug of abuse, a medication) or a (e.g., a drug of abuse, a medication) or a general medical condition general medical condition

Common Obsessions and Common Obsessions and CompulsionsCompulsions

ObsessionsObsessions ContaminationContamination Harm to self or Harm to self or othersothers

Need for Need for symmetry/ordersymmetry/order

Religious or Religious or moral concernsmoral concerns

Sexual or Sexual or aggressiveaggressive

Lucky or unlucky Lucky or unlucky numbersnumbers

CompulsionsCompulsions CleaningCleaning Checking, Checking, counting, counting, repeatingrepeating

Ordering, Ordering, straighteningstraightening

Praying, Praying, confessing, confessing, reassurance reassurance seekingseeking

Touching, Touching, tapping, or tapping, or rubbingrubbing

HoardingHoarding

OCD: Prevalence and CourseOCD: Prevalence and Course

PrevalencePrevalence 1-4% of children and adolescents1-4% of children and adolescents Ratio of boys to girls is 2:1 in Ratio of boys to girls is 2:1 in childhood; equalizes in adolescencechildhood; equalizes in adolescence

80% of all cases have childhood onset80% of all cases have childhood onset CourseCourse

Age of onsetAge of onset Males 6 - 15 years (peak 10); Females Males 6 - 15 years (peak 10); Females 20 - 29 years 20 - 29 years

Onset typically gradual, some acute Onset typically gradual, some acute Chronic waxing and waning of symptomsChronic waxing and waning of symptoms Stress exacerbates symptoms Stress exacerbates symptoms Estimated that 15% display progressive Estimated that 15% display progressive deterioration in social & occupational deterioration in social & occupational functioningfunctioning

Case ExampleCase Example

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

Post-traumatic Stress DisorderPost-traumatic Stress DisorderDSM CriteriaDSM Criteria

A. ExposureA. Exposure Person exposed to a event that involved Person exposed to a event that involved threat of harm/death to self or otherthreat of harm/death to self or other

Person’s response involved intense Person’s response involved intense fear, helplessness, or horrorfear, helplessness, or horror

B. Traumatic event is re-experienced B. Traumatic event is re-experienced (1+)(1+) Recurrent and intrusive recollections Recurrent and intrusive recollections (play)(play)

Recurrent and distressing dreamsRecurrent and distressing dreams Acting or feeling as if event were Acting or feeling as if event were recurring (reenactment)recurring (reenactment)

Intense distress at exposure to Intense distress at exposure to internal or external cues that resemble internal or external cues that resemble an aspect of the eventan aspect of the event

Physiological reactivity on exposure to Physiological reactivity on exposure to cuescues

PTSDPTSDDSM CriteriaDSM Criteria

C. Persistent avoidance of stimuli C. Persistent avoidance of stimuli associated with trauma and numbing associated with trauma and numbing of general responsiveness (3+)of general responsiveness (3+) Efforts to avoid thoughts/feelings Efforts to avoid thoughts/feelings about eventabout event

Efforts to avoid activities, places, Efforts to avoid activities, places, people related to eventpeople related to event

Inability to recall an important aspect Inability to recall an important aspect of traumaof trauma

Markedly diminished interest or Markedly diminished interest or participation participation

Feeling of detachment from othersFeeling of detachment from others Restricted range of affectRestricted range of affect Sense of foreshortened futureSense of foreshortened future

PTSDPTSDDSM CriteriaDSM Criteria

D. Persistent symptoms of D. Persistent symptoms of increased arousal (2+)increased arousal (2+) Difficulty falling or staying Difficulty falling or staying asleepasleep

Irritability or outbursts of angerIrritability or outbursts of anger Difficulty concentratingDifficulty concentrating HypervigilanceHypervigilance Exaggerated startle responseExaggerated startle response

E. Duration of symptoms > 1 E. Duration of symptoms > 1 monthmonth

Associated Characteristics Associated Characteristics of Anxiety Disordersof Anxiety Disorders

Cognitive disturbancesCognitive disturbances Interference with academic performanceInterference with academic performance Attentional biases (toward threat)Attentional biases (toward threat) Cognitive biases (negative spin on Cognitive biases (negative spin on ambiguous situations)ambiguous situations)

Physical symptomsPhysical symptoms Sleep Sleep Aches/painsAches/pains

Social and emotional deficitsSocial and emotional deficits Interference Interference Low self-esteemLow self-esteem LonelinessLoneliness

EtiologyEtiology

Anxiety arises from a complex Anxiety arises from a complex interaction of specific interaction of specific characteristics related to the child characteristics related to the child (e.g., biological, psychological, (e.g., biological, psychological, and genetic factors) and his or her and genetic factors) and his or her environment (e.g., conditioning, environment (e.g., conditioning, observational learning, family observational learning, family relations, traumatic events) relations, traumatic events)

Focus on four most recognized modelsFocus on four most recognized models BiologicalBiological BehavioralBehavioral CognitiveCognitive EcologicalEcological

EtiologyEtiology

BiologicalBiological Genetic InfluencesGenetic Influences

Biological vulnerability to inherit a Biological vulnerability to inherit a fearful disposition fearful disposition

Genetic influences account for 1/3 of Genetic influences account for 1/3 of variancevariance

Neurobiological factorsNeurobiological factors Within the limbic system, the Within the limbic system, the behavioral inhibition system behavioral inhibition system is is overactiveoveractive

Increased tendency to become over-reactive Increased tendency to become over-reactive and withdraw in response to novel and withdraw in response to novel stimulationstimulation

Irritable, shy, cautious, and quiet Irritable, shy, cautious, and quiet temperamenttemperament

EtiologyEtiology

Biology, continuedBiology, continued Neurochemical factorsNeurochemical factors

Abnormal function of serotonin, Abnormal function of serotonin, norepinephrine, dopamine, and GABA norepinephrine, dopamine, and GABA

EtiologyEtiology

BehavioralBehavioral Mowrer’s Two Stage Model of Mowrer’s Two Stage Model of Conditioning Conditioning

Acquisition of fear through Acquisition of fear through classical classical conditioningconditioning

An individual associates a threatening An individual associates a threatening stimulus with a nonthreatening stimulus, stimulus with a nonthreatening stimulus, so that the latter by itself triggers so that the latter by itself triggers anxietyanxiety

Maintenance of fear through Maintenance of fear through operant operant conditioningconditioning

Negative reinforcement is manifested by Negative reinforcement is manifested by avoidance and/or escape learningavoidance and/or escape learning

Consequently, without opportunities for Consequently, without opportunities for new learning provided by exposure, the new learning provided by exposure, the fear/anxiety does not extinguishfear/anxiety does not extinguish

EtiologyEtiology

Behavioral, continuedBehavioral, continued Observational learningObservational learning

Children learn about anxiety-Children learn about anxiety-provoking situations by provoking situations by

observing others experience such observing others experience such situations or situations or

by acquiring information through by acquiring information through activities like reading or watching the activities like reading or watching the news on television news on television

EtiologyEtiology

CognitiveCognitive Attentional biases toward threat-Attentional biases toward threat-related informationrelated information

Selectively attend to information that may be Selectively attend to information that may be potentially threateningpotentially threatening

Distorted judgments of riskDistorted judgments of risk Negative spin on ambiguous/non-threatening Negative spin on ambiguous/non-threatening situationssituations

Lead them to select avoidant solutionsLead them to select avoidant solutions

Selective memory processingSelective memory processing Tendency to remember anxiety-provoking Tendency to remember anxiety-provoking cues/experiencescues/experiences

Perfectionistic beliefsPerfectionistic beliefs Inflated sense of responsibility Inflated sense of responsibility

EtiologyEtiology

EcologicalEcological Bidirectional relationships among Bidirectional relationships among child, family, and other child, family, and other environmental contributions to environmental contributions to anxietyanxiety

Child temperamental characteristics Child temperamental characteristics (i.e., behavioral inhibition) X (i.e., behavioral inhibition) X insecure parent-child attachment X insecure parent-child attachment X anxious and controlling parenting anxious and controlling parenting styles styles

Parental modeling of fear Parental modeling of fear responsesresponses

Community violenceCommunity violence

Assessment Assessment

Diagnostic InterviewsDiagnostic Interviews Anxiety Disorders Interview Anxiety Disorders Interview Schedule for DSM-IVSchedule for DSM-IV

Schedule for Affective Disorders Schedule for Affective Disorders and Schizophrenia for School-Age and Schizophrenia for School-Age ChildrenChildren

Clinician-administeredClinician-administered ComprehensiveComprehensive Time-consuming and labor-intensiveTime-consuming and labor-intensive

AssessmentAssessment

Rating ScalesRating Scales Screen for Child Anxiety Related Screen for Child Anxiety Related Emotional Disorders - Revised Emotional Disorders - Revised (SCARED)(SCARED)

Multidimensional Anxiety Scale for Multidimensional Anxiety Scale for Children Children

Fear Survey Schedule for Children Fear Survey Schedule for Children – Revised – Revised

Also, disorder-specific measuresAlso, disorder-specific measures Quick and easy to administerQuick and easy to administer Standardized with good Standardized with good psychometric propertiespsychometric properties

Can be used as screening devices Can be used as screening devices *not to diagnose*not to diagnose

AssessmentAssessment

ObservationObservation Social-evaluative tasks (e.g., Social-evaluative tasks (e.g., classroom presentation)classroom presentation)

Behavioral avoidance to phobic Behavioral avoidance to phobic stimulusstimulus

Parent-child interactionParent-child interaction

Self-monitoring proceduresSelf-monitoring procedures Quantify and describe symptomsQuantify and describe symptoms

TreatmentTreatment

Behavioral and Cognitive-Behavioral and Cognitive-Behavioral Treatments have Behavioral Treatments have received most empirical supportreceived most empirical support

Pharmacotherapy has recently Pharmacotherapy has recently received promising supportreceived promising support Selective Serotonin Reuptake Selective Serotonin Reuptake Inhibitors (SSRIs)Inhibitors (SSRIs)

Psychodynamic and Family Psychodynamic and Family therapies have not received therapies have not received much empirical supportmuch empirical support

TreatmentTreatment

Treatments should target the 3 Treatments should target the 3 interrelated symptomsinterrelated symptoms Physical symptomsPhysical symptoms

Rapid heart beatRapid heart beat Muscle tensionMuscle tension InsomniaInsomnia

Cognitive symptomsCognitive symptoms Distorted perceptions of threatDistorted perceptions of threat

Behavioral symptomsBehavioral symptoms AvoidanceAvoidance EscapeEscape

Behavioral TherapyBehavioral Therapy

Exposure TherapyExposure Therapy Systematic DesensitizationSystematic Desensitization Relaxation ExercisesRelaxation Exercises Contingency Management Contingency Management StrategiesStrategies

ModelingModeling

Exposure Exposure

Create fear hierarchyCreate fear hierarchy List of fearful events, rated on List of fearful events, rated on 0-100 scale from least to most 0-100 scale from least to most anxiety-provokinganxiety-provoking

Example: Fear of snakesExample: Fear of snakes Talk about snakesTalk about snakes 33 See pictures of snakesSee pictures of snakes 55 Watch movies of snakesWatch movies of snakes 66 Touch a rubber snakeTouch a rubber snake 88 Go to pet store and hold snakeGo to pet store and hold snake 1010

Gradual exposure: Child confronts Gradual exposure: Child confronts fear fear

Exposure with Response Exposure with Response PreventionPrevention

Obsessive-compulsive disorderObsessive-compulsive disorder In addition to exposures, the In addition to exposures, the child is asked to refrain from child is asked to refrain from engaging in compulsive ritualsengaging in compulsive rituals

ExampleExample Touches floor of public bathroom Touches floor of public bathroom (exposure)(exposure)

Does not engage in handwashing Does not engage in handwashing (response prevention)(response prevention)

Proposed therapeutic mechanism Proposed therapeutic mechanism of exposureof exposure Break the conditioned fear Break the conditioned fear responseresponse

Consequently, acquire new, less Consequently, acquire new, less threatening (and more adaptive), threatening (and more adaptive), fear representationsfear representations

Systematic Systematic DesensitizationDesensitization

3 Steps3 Steps Teach child to relaxTeach child to relax Construct fear hierarchyConstruct fear hierarchy Present anxiety-provoking stimuli Present anxiety-provoking stimuli sequentially as child remains sequentially as child remains relaxedrelaxed

Proposed therapeutic mechanismProposed therapeutic mechanism Break the conditioned fear Break the conditioned fear response, because relaxation is response, because relaxation is incompatible with fear responseincompatible with fear response

Which is better???Which is better???

RelaxationRelaxation

Deep breathingDeep breathing ImageryImagery Progressive Muscle RelaxationProgressive Muscle Relaxation Proposed therapeutic mechanismProposed therapeutic mechanism

Increased control over sympathetic Increased control over sympathetic nervous systemnervous system

Decreased physiological symptomsDecreased physiological symptoms

Reinforced PracticeReinforced Practice

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

ModelingModeling

Filmed modelingFilmed modeling Live modelingLive modeling Participant modelingParticipant modeling

Cognitive-Behavioral Cognitive-Behavioral TherapyTherapy

In addition to behavioral In addition to behavioral strategies…strategies…

Teaches children to understand Teaches children to understand how thoughts contribute to how thoughts contribute to anxietyanxiety

And how to modify distorted And how to modify distorted thoughts to decrease symptomsthoughts to decrease symptoms

THOUGHTS BEHAVIOR

FEELINGS

Cognitive-Behavioral Cognitive-Behavioral TherapyTherapy

ComponentsComponents Psychoeducation about nature of Psychoeducation about nature of symptomssymptoms

Skill buildingSkill building Cognitive restructuringCognitive restructuring Positive self-talkPositive self-talk Problem solvingProblem solving Approach-oriented copingApproach-oriented coping Relaxation strategiesRelaxation strategies

ExposureExposure Role playRole play Contingency reinforcement: rewards Contingency reinforcement: rewards

Coping Cat: CBT for Anxiety Coping Cat: CBT for Anxiety

Developed by Phil Kendall at Temple Developed by Phil Kendall at Temple UniversityUniversity

It is based on basic Cognitive It is based on basic Cognitive Behavioral PrinciplesBehavioral Principles

Treatment typically takes place Treatment typically takes place across 16 sessions where the child is across 16 sessions where the child is taught:taught: how to recognize their physical reactions how to recognize their physical reactions and anxious feelings when confronted with and anxious feelings when confronted with anxiety related stimulianxiety related stimuli

to become aware of anxiety-related to become aware of anxiety-related cognitionscognitions

to develop a coping plan for dealing with to develop a coping plan for dealing with anxiety that involves positive self anxiety that involves positive self statements and problem solving skillsstatements and problem solving skills

Coping CatCoping Cat

The child is also taught to evaluate The child is also taught to evaluate their coping responses and apply their coping responses and apply self-reinforcement for adaptive self-reinforcement for adaptive coping behaviorscoping behaviors

Children are encouraged to engage in Children are encouraged to engage in both imaginal and in vivo exposure both imaginal and in vivo exposure to anxiety related stimuli, while to anxiety related stimuli, while using the skills they have been using the skills they have been taughttaught

In-session and out-of-session In-session and out-of-session activities are used to give children activities are used to give children opportunities to use skills opportunities to use skills

Therapists also reinforce the Therapists also reinforce the successful use of coping skillssuccessful use of coping skills

SADSAD

Behavioral components:Behavioral components:

Cognitive components:Cognitive components:

Extra targets: School refusalExtra targets: School refusal

Social PhobiaSocial Phobia

Behavioral components:Behavioral components:

Cognitive components:Cognitive components:

Extra targets: Social Skills Extra targets: Social Skills TrainingTraining

Generalized Anxiety Generalized Anxiety DisorderDisorder

Behavioral componentsBehavioral components

Cognitive componentsCognitive components

Extra targets: Reassurance Extra targets: Reassurance seekingseeking

Specific PhobiaSpecific Phobia

Behavioral componentsBehavioral components

Mostly transient conditionsMostly transient conditions

OCDOCD

Behavioral components:Behavioral components:

Cognitive components:Cognitive components:

Extra Targets: Medications Extra Targets: Medications SSRIs: Luvox, Paxil, Prozac, and SSRIs: Luvox, Paxil, Prozac, and ZoloftZoloft

Majority of children on medication Majority of children on medication improve, but may relapse and need improve, but may relapse and need further treatment.further treatment.

PTSDPTSD

Trauma-focused CBTTrauma-focused CBT

1.1. psychoeducation and parenting psychoeducation and parenting skillsskills

2.2. relaxationrelaxation

3.3. affective modulation: identifying affective modulation: identifying and coping with negative emotionsand coping with negative emotions

4.4. cognitive strategiescognitive strategies

5.5. trauma narrativetrauma narrative

6.6. in vivo mastery of trauma in vivo mastery of trauma remindersreminders

7.7. conjoint child-parent sessionsconjoint child-parent sessions

8.8. enhancing future safety and enhancing future safety and development development

Any QuestionsAny Questions