Internalising disorders: Anxiety, Depression

Question 1

Classification of childhood disorders

Answer 1

 Achenbach classified children’s psychopathology according to dimensions.
 Two most common dimensions are externalising and
internalising disorders. Children are diagnosed with a
disorder (e.g. DSMV) when they exceed a certain number of symptoms and its considered a significant impairment.
 Internalising dimension refers to ‘holding in’, or behaviours that are directed inward.
 Typically include anxious and/or depressed problems,
withdrawal, and somatic complaints.
 N.B. Children may display both internalising and externalising difficulties (i.e., comorbidity).
(Ref. Parritz and Troy, 2014)

Question 2

childhood anxiety disorders

Answer 2

Anxiety Disorders (AD) are amongst the most common forms of psychopathology in children and adolescents.
 Costello et al. (2004) found that the median prevalence rate for anxiety disorders in children was 8.1%.
 More common in females.
 Frequently comorbid with other anxiety and depressive disorders, and some types of externalizing disorders (ADHD and conduct problems).
 Children with internalizing disorders receive treatment less frequently than those with externalizing problems (Garland et al., 2000; Rapee et al., 2008 etc)
Anxiety Disorders are often unrecognised and not referred. Why?

Question 3

Consider what is ‘normal’ fear/anxiety?

Answer 3

Normative age/developmental related experiences
(e.g., anxiety about separation from parents at crèche/kindergarten).
Stimuli that elicit fear changes at different ages/stages of development e.g., strangers and separation in infancy, or robbers and the dark in toddler years (n.b. young children can’t distinguish fantasy from reality).
Developmental focus is important.
[See Carr Table 12.1 depicting fears at different ages
on pg.400 for further information].

Question 4

Features of Anxiety Disorders in children

Answer 4

 Persistent anxious or fearful mood which can be triggered by particular situations (e.g. bedtime or school drop offs) or generalised across a number of situations.
 See Carr (pp. 423-424 Table 12.8) and DSMV for clinical features of anxiety disorders.
 Variations in features across ADs
 E.g Separation anxiety-perceived as threatening, child believes harm to self or parent will occur, child has intense fear or anger during/after separating, separation is avoided (e.g., may refuse to go to school)and may have sleep problems/hyperarousal, may impact academic/social functioning (Carr, 2015).

Question 5

When do AD’s typically present?

Answer 5

 Separation anxiety disorder (preschool onwards)
 Selective mutism (usually presents before 5)
 Specific phobias-median age of onset 7-11 years
 Social anxiety disorder (8-15 years, median 13 years)
 Generalised anxiety disorder (adolescence and adulthood-median age 30)
 Anxiety due to medical states (different ages)
Note: DSMV arranges disorders according to typical age of onset.

Question 6

309.21 Separation Anxiety Disorder

Answer 6

Developmentally inappropriate excessive fear or anxiety concerning separation from home/attachment figure.
Must meet 3 of 8 DSMV criteria, e.g.
 Distress around separations from major attachment figures,
 Repeated nightmares with themes of separation,
 Persistent and excessive worry about losing attachment figure (e.g., parent dying) or harm to them
 Persistent worry about an untoward event that causes separation (e.g. illness),
 Persistence reluctance or refusal to go away from home/go to school…
 Repeated somatic complaints when separations occur or when anticipating separations from major attachment figure.
o Fear, anxiety, avoidance is persistent, lasting at least 4 weeks in children and adolescents
o Disturbance causes clinically significant distress/impairment in functioning

Need to rule out differential diagnosis:
e.g., Social anxiety disorder-e.g, school refusal due to worry about being judged negatively by others rather than due to separation from attachment figure.

Question 7

Separation anxiety youtube video

Answer 7

 https://www.youtube.com/watch?v=58khDBvteTs

Question 8

312.23 Selective Mutism

Answer 8

 A. Consistent failure to speak in specific social situations (e.g., school) where there is an expectation to speak, despite speaking in other situations
 B. Interferes with educational/occupational achievement/social communciation
 C. Duration at least 1 month (not limited to 1st month of
school)
 D. Not attributed to lack of knowledge of/comfort with spoken language required in social situation.
 Not better explained by another disorder e.g ASD/communication disorder.

Question 9

Specific Phobia

Answer 9

A. Marked fear/anxiety about a specific object or situation (e.g., insects/heights).
 In children fear can be expressed via crying/clinging/tantrums etc.
 B. Phobic object/situation almost always provokes immediate fear/anxiety.
 C. …….actively avoided/endured with intense fear/anxiety.
 D. Fear/anxiety if out of proportion for the situation
 E. Persistent….Typically lasting 6 months or more
 F. Causes clinically significant distress/impairment in
functioning
 G. Not better explained by another condition
Specifiers/codes for phobic stimulus e.g animals, blood etc

Question 10

300.23 Social Anxiety Disorder

social phobia

Answer 10

 A. Marked fear/anxiety of one or more social situations in which the individual is exposed to possible scrutiny by others (e.g., public
speaking, meeting new people, giving a speech etc).
 In children must occur with peers and not just adults.
 Social situations almost always provoke fear/anxiety.
 Note, in children can be expressed as crying, freezing,
tantrums etc.
 Total of 10 criteria to be met (e.g., anxiety is not consistent with the threat posed by the situation; causes clinical distress; symptoms are persistent & have occurred for at least 6 months etc).
 Differential diagnosis: GAD, Selective mutism etc
 Specify if: fear is restricted to speaking/performing in public.

Question 11

Generalized Anxiety Disorder

Answer 11

A. Excessive anxiety and worry about a number of
events/activities; occurring more days than not for at least 6 months.
B. Individual finds it hard to control the worry
C. Anxiety is associated with (3/6 symptoms in adults and) only 1 symptom in children: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
D. Causes significant distress/impairment in functioning
E Not due to a substances (e.g., drug)/medical condition
F. Not better explained by another mental disorder

Question 12

How may an anxious child present?

Answer 12

Problems may be less apparent than children with behavioral disorders (e.g. in classrooms)
 Children may appear perfectionistic; “well behaved”; but may perform poorly in school
 Somatic complaints (cultural influences)& in extreme cases emergency visits
 Anxiety may also present as oppositional behavior, such as through avoidance of tasks or school refusal
 In the clinic –clingy, quiet/reserved, fidgety/restless, avoidant, angry (e.g., at parents for bringing them), controlling…
 Other clinical observations?

Question 13

The Role of the Family anx

Answer 13

 Anxious children often have anxious parents
-Genetic impact
- Anxious modeling
 Parents of children with anxiety disorders are theorized to be:
- More over-controlling/over-protective
- Less warm, more rejecting
(see Bogels & Brechman-Toussaint article on canvas)

Question 14

Best practice assessment anx

Answer 14

A comprehensive assessment that combines information from parent, child, teachers and clinicians’ observations is recommended.
 Include measure(s) of symptoms.
 N.B. Children may not be able to describe all their physical or emotional symptoms and parents & teachers (with permission) can be helpful in describing what they have noticed about the child.

Question 15

Assessment Tools anx

Answer 15

Broad rating tools e.g., CBCL/BASC for initial screen
 Spence Anxiety Scale (children, teachers and parents)
http://scaswebsite.com/
 The Anxiety Disorder Interview Schedule for Children (ADISC)-gold standard but time consuming
 See Macquarie link for resources and assessment tools:
https://www.mq.edu.au/research/research-centres-groups-andfacilities/healthy-people/centres/centre-for-emotional-health-ceh/resources

Question 16

When considering interventions with

children

Answer 16

Be mindful of the child’s cognitive development e.g., abstract reasoning skills-8 plus
 Need to make abstract concepts more concrete (e.g., use cartoons, diagrams, age appropriate examples etc)
 CBT for younger children (pre-schoolers) includes a parent component e.g., teach parent skills for managing at home
 The therapeutic learning experience should generalise beyond the clinic setting (e.g., child learns to problem solve and in time can apply to other social situations).

Question 17

Treatment –what works? anx

Answer 17

Reference: Fonagy et al (2015) What works for whom?
 In general, involving parents in treatment planning and treatment is beneficial.
 Often parents anxious/over involved thus psycho-ed. can be an important component of treatment.

 CBT considered ‘best practice’ with children with ADs. E.g., Level II evidence for use of CBT with GAD aged 7-17 years (APS review, 2018).
 Use behavioural strategies with younger children
 Use CBT + additional modules (eg trauma/panic control) for specific types of ADs/presenting problems e.g., PTSD
 Exposure treatment needs to be gradual but supportive approach (parental involvement)
 Consider Online CBT programs (Level II evidence for OCD and SAD) (APS, 2018)
- Structured psychodynamic therapy (e.g., play therapy): some evidence for effectiveness but not considered ‘best practice’ at this time.
- Mindfulness-emerging evidence base.

Question 18

Summary of evidence based treatment findings anx

Answer 18

Parent self-help can be good first line for ‘at risk’
children
Preferred approach is a family-based (CBT)
approach involving children and their parents
CBT for children with anxiety produce marked
reductions in symptoms that are maintained over time
(approx 55-60% recovery rates following 10-16
sessions CBT).
CBT group treatment has comparable outcomes
and reduced costs.
- SSRI’s also effective-should be prescribed by
specialists (eg paeds/child psychiatrists) with close
monitoring for side effects.
- CBT+SSRI-superior to CBT or medn alone (Hudson
et al 2014).

Question 19

CBT programs for children

Answer 19

Typically include:
 Psycho-education
 Affect recognition (feelings and body cues)
 Cognitive restructuring
 Relaxation skills
 Gradual exposure
 Coping skills
 Some examples of CBT programs follow…
Note: Resources have been put up on canvas

Question 20

Overview of Kendall’s Coping Cat Program (7-13 years)

Answer 20

Part 1
Child learns when he is anxious
Child learns coping skills
F-E-A-R Plan (coping skills). Feeling frightened, Expecting bad things to happen, Actions and attitudes that can help, Results and rewards.
 Part 2
Exposures: gradual and repeated practices to feared situations
 2 Parent Sessions
 School involvement (if necessary)
Kendall, P. C., & Hedtke, K. (2006). Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual (3rd ed.). Ardmore, PA: Workbook
Publishing. www.WorkbookPublishing.com

Question 21

Part 1: Psychoeducation and Skill-building

Answer 21

Build rapport; develop an understanding of his/her
experience with anxiety

Psychoeducation
Recognizing feeling (cues child into their anxiety)
Physiological responses to anxiety
Explore parent/family variables that contribute

Skill-building
Relaxation Training
Cognitive techniques
Problem-solving
Self-examination and self-reward

Question 22

Part 2: Exposure and practice

Answer 22

Behavioural hierarchy and exposure often used for anxiety in younger children (e.g., phobias, social anxiety etc)
1. First establish contract, psycho-education and skill building (e.g., breathing/relaxation techniques) -over several sessions
2. Preparation in sessions
 Child knows exposure in advance and agrees
 Make a plan around the situation child is being exposed
 Practice/Rehearsals/Role-Play
3. Exposure (in and out of session) e.g. ringing friend in session … going to a party for a child with social anxiety. Parent and child both prepared plan and strategies etc
4. Following the Exposure (e.g. next session)
How does the child think he/she did?
Reward the child after the exposure (praise etc).

Question 23

Hierarchy of fears

Answer 23

Establish list from least to most concerning
 E.g., Boy with a fear of dogs
 Least = watch a movie with a dog
 Most = being near a dog running around in park without a leash
 What is his fear about for each one? (explore and gain an understanding)

Question 24

Child Exposure to social situations

Answer 24

 Use child’s fear hierarchy (pyramid of fears)
 Aim is not to remove anxiety, but to be able to manage it, so child should experience anxiety for treatment to be effective.
 Needs opportunity to practice and experience success
 Gradual (step-by-step approach) e.g. ringing someone in your office with you present to support them and build from there…
 Repetition is the key to success.
 Stay in the situation until the anxiety decreases (child will have learnt strategies in earlier sessions e.g., positive self talk and deep breathing taught in earlier sessions and is reminded to
use them).
 Need to work with the parent and their reactions to the child’s anxiety in order to make change . Anxiety - genetic and learnt and parenting style often more overprotective etc. Sessions with parents are often a part of the treatment plan. Also feedback to teachers helpful for consistency.

Question 25

Cool Kids: Content Overview

Answer 25

Psycho-education
Cognitive restructuring
(Detective thinking)
Child management
In vivo exposure (plus rewards)
Skills training

Comprises the following sessions:
 Session 1 – What, Why and How? An Overview of the Program
 Session 2 – Learning to Think Realistically (cognitive restructuring)
 Session 3 – Detective thinking and self rewards
 Session 4 – Fighting Fear by Facing Fear-step ladder
 Session 5 – Creative Exposure-step ladder and worry surfing
 Session 6-9 – Building Skills While Facing Fears-e.g., social skills
 Session 10 – Maintaining Gains and Coping with Set-Backs
8–10 X 1 hour sessions with children, which is also supplemented by 2 parent information sessions (each 2 hours in length), and 1–2 individual consultations with parents

Question 26

Online CBT: Brave program

Answer 26

emergingminds.com.au/resources/brave-anxiety-onlinetreatment- program/
Free online CBT resource for children and parents
Child (8-12) and adolescent (12-17) versions developed through University of QLD.
Consider as an adjunct to therapy e.g child completes
concurrently with face to face or online sessions

Question 27

The nature of depression

Answer 27

Depression is one of the most common internalising disorders in young people
 May lead to serious consequences such as school absenteeism and decreased educational attainment.
 Whilst the majority of children recover from depression within a year, having a depressive episode during childhood increases the
risk for occurrence of a later episodes of mood disorder in adulthood but does not increase the risk of other psychopathology (Carr, 2015).
 Relapse rates are high (70%).