ANXIETY DISORDERS IN CHILDREN

Question 1

OVERVIEW OF ANXIETY IN CHILDREN

Answer 1

Research into childhood anxiety has lagged behind that of adults, but has increased rapidly since the 1980’s / 90’s

Anxiety disorders are one of the most prevalent emotional problems of childhood (e.g., Barrios & Hartmann, 1997)

However, specific fears and anxieties are also one of the normal developmental challenges that face maturing individuals

Question 2

COMMON CHILDHOOD FEARS

Answer 2

8 MONTHS TO 2 YRS - SEPARATION FROM PRIMARY CAREGIVER
2-4 FEAR OF THE DARK AND ANIMALS
4-6 FEAR OF MONSTERS AND GHOSTS
6*+ FEAR ON INJURY TO SELF AND OTHERS AND DEATH ALSO NATURAL CATASTROPHES
ADOLESCENCE- FEAR OF APPEARANCE,SOCIAL FEARS AND SCHOOL PERFORMANCE

Question 3

The Features & Characteristics of Childhood Anxiety Problems

Answer 3

Behavioural, cognitive and emotional aspects

Primarily manifested as withdrawn behaviour (internalizing)

Children avoid activities and are clinging and demanding of parents and carers

Anxious children report significantly more somatic complaints (Hofflich et al., 2006)

Question 4

The Aetiology of Childhood Anxiety Problems

Answer 4

Genetic Factors
Trauma & Stress Experiences
Modelling & Exposure to Information
Parenting Style &
Parent-Child Interaction

Question 5

Genetic Factors

Answer 5

Twin studies suggest a significant but modest inherited component

Both heritable and environmental factors appear to be important (Lichtenstein & Annas, 2000)

May be different for specific anxiety disorders

State vs. trait anxiety (Lau et al., 2006)

Question 6

Trauma & Stress Experiences

Answer 6

There are clear links between extreme stressful experiences (e.g. childhood physical and sexual abuse) and childhood anxiety (Feerick & Snow, 2005)

Events such as living with illness, the death of a pet, and minor road accidents can cause significant childhood anxiety

Question 7

Modelling & Exposure to Information

Answer 7

Exposure to information about threats can cause children to develop fears and phobias without direct experience (Field, 2006)

For e.g., observation of parents reactions and behaviour patterns, or listening to parents explanations (Barrett et al., 1996)

Also influence of information from media and peers

Question 8

Parenting Style

Answer 8

Overprotective and overanxious parents may invoke anxiety in the child (Rapee, 1997)

Overprotective parenting may increase the child’s perception of threat and reduce their sense of control (Van der Bruggen et al., 2008)

Children who experience rejecting or detached parents also show increased levels of anxiety (Chartier, Walker & Stein, 2001)

Question 9

Childhood Anxiety Disorders

Answer 9

Generalized Anxiety Disorder (GAD)
Obsessive-Compulsive Disorder (OCD)
Specific Phobias (e.g., School Phobia)

Separation Anxiety Disorder (SAD)
Selective Mutism (SM)

Question 10

Separation Anxiety

Answer 10

An intense and developmentally inappropriate fear of being separated from parents or carers

May develop exaggerated fears that parents may become ill, die or be unable to look after them

Consequences include reluctance to attend school or to require parents to stay with them until they fall sleep

Question 11

Changes in the DSM 5

Answer 11

Acceptance of SAD in adulthood:

Age of onset after 18 years
Modification of criteria wording (e.g., attachment figures, workplace)
Duration criteria: ‘typically lasting 6 months or more’

Question 12

SAD and Parenting Style

Answer 12

Parental intrusiveness is linked to SAD in children predisposed to or currently experiencing anxiety (Wood, 2006)

Intrusiveness involves:
Unnecessary assistance with daily self-help tasks
Infantilising behaviour (e.g., excessive affection)
Invasions of privacy

Developmentally inappropriate for the child’s age

Question 13

Selective Mutism

Answer 13

A persistent failure to speak in certain social situations

Excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism

May involve temper tantrums or oppositional behaviour, particularly at home

Question 14

Diagnostic Criteria

Answer 14

Lasts at least a month (but not the first month of school)

Cannot be better accounted for by a communication disorder

Interferes with educational or occupational achievement, or with social communication

Does not occur exclusively within the course of a pervasive developmental or psychotic disorder

Question 15

Key Issues

Answer 15

A relatively rare and under-researched disorder

Complicated co-morbidity issues

Rather than an oppositional disorder, SM is increasingly considered as an anxiety disorder (a specific childhood manifestation of social phobia; Anstendig, 1999; Kristensen, 2000).

Aphasia voluntaria > elective mutism (ICD-10) > selective mutism (DSM-IV-TR)> DSM 5 now classified as an anxiety disorder

Question 16

General Treatment Issues

Answer 16

Pharmacological: use of antidepressant or anti-anxiety medications? (e.g., Sertraline)

Psychotherapeutic: wide use of and support for CBT (Hirshfeld et al., 2010)

Combined approach? (See Ginsburg et al., 2011 CAMS study)

Specificity for distinct anxiety disorders?

Question 17

Childhood CBT: Key features

Answer 17

Involves use of Psychoeducation

Developmentally appropriate tools and materials

Focus upon identification of symptoms

Imaginal exercises and relaxation techniques

Exposure is crucial (Barlow, 1988; Blagg & Yule, 1984)

Involvement of parents?

Question 18

Parental Involvement

Answer 18

Parent as ‘coach’ who is directly involved with behavioural management.

Identify problem, break it down, try a strategy, then evaluate strategy

Parental involvement differs between programs,. Can be associated with improved outcomes (e.g., Barrett, Dadds, & Rapee, 1996; Mendelowitz et al., 2002) but results are not consistent (e.g., Nauta et al., 2001; 2003).

Question 19

Treatment of Selective Mutism

Answer 19

Traditionally considered to be difficult to treat (e.g., Kolvin & Fundudis, 1981)

Treatment reconsidered in light of reappraisal as an anxiety disorder

Successful use of behavioural approaches(e.g., contingency management, stimulus fading, systematic desensitisation and self modelling)

Promising use of CBT approaches (Fung et al., 2002)
Limited and methodologically weak research in this area

Multi-modal, multi-agency approach seems most appropriate (Standart & Le Couteur, 2003)

Treatment should continue after the achievement of speech

Question 20

Alternative Methods: Computerised CBT (See Kendall et al., 2011)

Answer 20

Computer-assisted or computer based

Preliminary research to support use in the treatment of adult anxiety disorders (e.g., Anderson, Jacobs & Rothbaum, 2004)

Camp-Cope-A-Lot (CCAL) for 7-12 year olds

Question 21

Khanna & Kendall (2010)

Answer 21

RCT comparing CCAL with traditional individual CBT (ICBT) and a computer assisted education program (CESA)

Significantly greater symptom reduction in ICBT and CCAL compared to CESA

At post-treatment 88% of individuals for CCAL no longer met diagnostic criteria for anxiety, compared to 77% for ICBT and 23% for CESA