Angela Lai

Shelina Hassanali
Christina Majcher
ANXIETY DISORDERS
Anxiety Disorders
Most common of all psychiatric disorders affecting children and
youth

Long-term outcomes of anxiety disorders in childhood and
adolescence are still not well understood

Research into childhood anxiety did not begin until the 1980s

Fears and anxieties are a part of normal childhood development,
but for some children this expectation may end up masking the
presence of an existing or emerging anxiety disorder

Less than 20% of children requiring support for any disorder receive
necessary intervention


Types of Anxiety Disorders

Separation Anxiety Disorder (SAD)

Panic disorders

Post-traumatic Stress Disorder

Acute stress disorder

Agoraphobia

Generalized anxiety disorder (GAD)

Social Anxiety Disorder

Obsessive Compulsive Disorder (OCD)
History of Anxiety Disorders
Childhood anxiety disorders have been referenced for decades.
However, study of pathological anxiety disorders in children began
in the latter part of the 20th century.

Fears and anxiety reactions in children were not acknowledged as
a classification of disease, but were studied and researched to
determine normal developmental reactions and classified according
to etiology.

The delay in attention towards childhood anxiety might have been
the result of disagreements amongst professionals in terms of what
constituted a clinical anxiety state, distinct from fears and anxieties


History of Anxiety Disorders (cont.)
The DSM-III and DSM-III- R provided first attempts to determine
developmentally appropriate diagnostic criteria for phobias and
anxiety disorders in children and adolescents.

In the DSM III, Children could be diagnosed with one of 3 childhood
disorders (Overanxious Disorder, Separation Anxiety Disorder or
Avoidant Disorder) as well as adult anxiety disorders (Phobic
Disorders, Obsessive-Compulsive Disorder, and Posttraumatic
Stress Disorder)

The addition of diagnostic criteria encouraged a large number of
studies examining the epidemiology and clinical characteristics of
phobias and anxiety disorders in children that have influenced the
changes and revisions in criteria for diagnosing anxiety disorders.



Epidemiology of Anxiety Disorders
Epidemiological samples show lower rates of anxiety disorders than
clinical studies show

Of 15 studies, 11 estimate the prevalence of childhood anxiety
disorders at greater than 10% (United States 12-20%)

There has been minimal research focusing on the demographic
composition of anxiety disorders. Consequently, it is very difficult to
come to any firm conclusions concerning racial, socioeconomic, or
gender patterns in childhood and youth anxiety disorders.

The efforts to understand the role of culture in childhood anxiety are
still in the early stages.


Etiological Models of Anxiety Disorders

Albano, Chorpita, and Barlow (Mash & Barkley, Eds., 2003, pp.
307-308) used the model of triple-vulnerability to describe the
development of anxiety and its disorders as a function of three
interacting dispositions:

a)Heritable biological diathesis
b)Generalized psychological vulnerability
c)Specific vulnerability



Etiological Models: Genetics
Genes contributed to a general risk factor for Anxiety Disorders.

Research findings suggested the followings:

Large-scale twins study: high monozygotic concordance for
some anxiety disorders, but not GAD
Studies of parents with Anxiety Disorders and their children:
anxiety: 7x more likely as control; anxiety 2x more likely than
dysthymic control
First- and Second- degree relatives: children show higher
prevalence of anxiety than relatives of control and relatives of
controls with ADHD
Covariance between anxiety and depression exists and was
accounted by heritable factor


Etiological Models: Temperament
Possibly heritable emotional and behavioural styles that are manifested in
early development of personality

Kagan's "behaviour inhibition model
Behaviour indicators: speech latency and speech frequency Physiology
indicators: heart rate, blood pressure

Kagan's longitudinal research: 15% of children are born predisposed to be
inhibited as infants
o Stability of temperament traits
Biederman's study of behavioural inhibition in high-risk children
Grays model of Behavioural Inhibition System
Big Five Model (Surgency/extraversion, agreeableness,
conscientiousness, emotional stability/neuroticism, and openness)


Psychosocial Factors
Recent research has been focusing on the identification of
possible mechanisms or processes that may establish or
intensify the risk for negative emotions such as coping
strategies, social/familial transmission, information processing,
and complex forms of conditioning

Chorpita (2001) proposed a model that explains the relations of
an individual's sense of control and the development of anxiety




Etiological Models - Parenting
Researchers have identified relevant modeling or conditioning
processes in family interactions that may serve to increase anxious
cognition
Parental modeling, prompting, and rewarding of anxious
behaviours
Family intervention
Cognitive-behavioral therapy + parent anxiety management

Parental rearing style: insufficient affection played a role for Panic
Disorder and GAD; control or overprotection had an impact on
Panic Disorder

Vicarious learning of anxiety: witnessing illness in family member;
parent and anxious children who spend a great deal of time
discussing potential threat of ambiguous situations

Common Comorbidities
Anxiety Disorders are identified as
associated with the features of the
following disorders:
Different types of Anxiety Disorders
(SAD and Panic Disorder)
GAD with OCD
OCD: Tic Disorder, MDD, specific
developmental disorder, simple
phobia, adjustment disorder with
depressed mood, ODD, ADHD
Social Anxiety: Eating Disorders,
Autism Spectrum Disorder, MDD,
Dysthymia, Substance Abuse
(Beidal et al., 2007); Grabhorn, Stenner, Stangier, & Kaufhold
(2006)

Three Anxiety Disorders:
Examined In-Depth

GENERALIZED ANXIETY DISORDER
(GAD)

OBSESSIVE COMPULSIVE DISORDER
(OCD)

SOCIAL ANXIETY DISORDER


Generalized
Anxiety Disorder
Excessive, uncontrollable
and often irrational worry
about everyday things that
is disproportionate to the
actual source of worry,
occurring more days than
not, for at least 6 months

To diagnose GAD in
children, there must also
be the presence of at least
one physiological
symptom.
GAD Core Symptoms

Children with GAD are often described as little worriers

Most frequent worries include tests/grades, natural disasters,
being physically attacked, future school performance, and social
relationships

Often worry about adult concerns, like family finances

Often described as placing high standards on themselves, self
conscious and require frequent reassurance from others

It is not the number of worries, but rather the intensity of the
worries that separates children with GAD from non-referred
children
GAD Related Symptoms
Younger children (ages 5-11) tend to present with comorbid
separation anxiety and ADHD

Older children (ages 12-19) comorbid with major depression and
simple (specific) phobia

Physical complaints are often associated, particularly headaches,
stomach aches, muscle tension, sweating and trembling

Adolescents (especially girls) with GAD also have a high
frequency of disturbing dreams
DSM-IV-TR Diagnostic Criteria
A. Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for at least 6 months, about a number of events or activities (such as work
or school performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms present for more days than not for the past
6 months). Note: Only one item is required in children.
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless sleep)

GAD Diagnostic Criteria (cont.)
D. The focus of the anxiety and worry is not confined to features of an Axis I
disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in
Panic Disorder), being embarrassed in public (as in Social Phobia), being
contaminated (as in ObsessiveCompulsive Disorder), being away from home or
close relatives (as in Separation Anxiety Disorder), gaining weight (as in
Anorexia Nervosa), having multiple physical complaints (as in Somatization
Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety
and worry do not occur exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.

F. The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition
(e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a
Psychotic Disorder, or a Pervasive Developmental Disorder.

GAD in the DSM V
A. Excessive anxiety and worry (apprehensive expectation) about two (or more)
domains of activities or events (e.g., family, health, finances, and school/work
difficulties).

B. The excessive anxiety and worry occurs on more days than not, for 3 months or more

C. The anxiety and worry are associated with one or more of the following
symptoms:
1. restlessness or feeling keyed up or on edge
2. muscle tension

D. The anxiety and worry are associated with one or more of the the following
behaviours:
1. marked avoidance of activities or events with possible negative outcomes
2. marked time and effort preparing for activities or events with possible negative
outcomes
3. marked procrastination in behaviour or decision making due to worries
4. repeatedly seeking reassurance due to worries



GAD in School Settings
Jacob's story.
http://youtu.be/4RSdV9R8wXQ

Children often display the following:






Can affect academic performance
Parents are often the ones to indicate to the school the intensity
of their child's worries


Physical complaints High rate of school absence
Tendency toward perfectionism Irritable
Test anxiety Fixate on worries
Internalizing/externalizing behaviours Low coping skills
Social challenges Difficulty concentrating
GAD Treatment and Interventions
Cognitive Behaviour Therapy
FRIENDS program- School-based anxiety prevention and
resiliency skill-building program, sponsored by the the Ministry
of Children and Family Development in British Columbia.















Obsessive
Compulsive
Disorder (OCD)

Recurrent and
intrusive obsessions
and compulsions that
are time-consuming,
or which cause
marked distress for
an individual and/or
significant
impairment in
functioning.
OCD Core Symptoms

Characterized by obsessions (cause anxiety) and/or
compulsions (neutralize anxiety)

What is the difference between obsessions and compulsions?
http://www.youtube.com/watch?v=_wEU-165NRY
(from 2:24)

Important to note that non-anxious children may also have
ritual-like behaviours that are not OCD (arranging toys,
night-time routines)

Distinguishing factor is that children with OCD will show
distress if ritual is altered

OCD Related Symptoms
Other anxiety disorders and depression (most common)

Early onset OCD is associated with higher severity of
depressive symptoms, increased risk for ADHD, GAD and
Specific Phobia

Eating disorders and personality disorders

In children, OCD may also be associated with LD and
Behaviour Disorders

Mood disorders may be more prevalent in adolescents with
OCD

High incidence of OCD in children and adults with Tourettes

DSM-IV-TR Diagnostic Criteria
A. Either obsessions or compulsions:
Obsessions are defined as:

(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 thoughts, impulses, or images are a
product of his or her own mind (not imposed from without as in thought insertion)


DSM-IV-TR Diagnostic Criteria (cont.)
Compulsions as defined as:

(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 excessive


DSM-IV-TR Diagnostic Criteria (cont.)
B. At some point during the course of the disorder, the person has realized that the
obsessions or compulsions are
excessive or unreasonable. Note: This does not apply to children (limited cognitive
awareness)

C. The obsessions or compulsions cause marked distress, are time consuming
(take more than 1 hour a day), or significantly interfere with the persons 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.

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




DSM-IV-TR Diagnostic Criteria (cont.)
Specify if:

With Poor Insight: if, for most of the time during the current episode, the person
does not recognize that the obsessions and compulsions are excessive or
unreasonable





OCD in the School Setting

Attendance may be impacted

Could cause social isolation (i.e. difficulty sharing items, playing
games, group work, sleepovers, etc)

School work and homework may be affected (i.e. checking,
erasing, doubting, impaired concentration, etc)

Adolescents may find increased independence anxiety-
provoking (i.e. dating, working, driving)

OCD Treatment and Interventions
Cognitive Behavioral Therapy (CBT)
o Cognitive Restructuring (changing thought patterns)
o Exposure & Response Prevention (ERP) (i.e. "exposure
therapy"/desensitization)
o Mindfulness (learning to be aware of and accept
uncomfortable psychological experiences)

Medicines
o SSRI's (to help balance chemicals in the brain)
o Sometimes used to make CBT more effective
o Can have side effects, need to be careful with children

(OCD Center of Los Angeles)
OCD Treatment and Interventions
Children's books:












By Holly L. Niner
By A.P. Wagner & P.A. Jutton
Social Anxiety
Disorder
(Social Phobia)
A marked and
persistent fear of
one or more social
or performance
situations in which
the person fears that
embarrassment may
occur.

Core Symptoms
Immediate anxiety responses or panic attack upon exposure of
the situation

Avoidance or extreme distress

Excessive concerns about embarrassment, negative evaluation,
and rejection; processing social situations negatively

Reports of autonomic symptoms and sensations
o Younger children: illnesses, crying
o Youth: fears of blushing, avoid others

Prevalence and Related Symptoms
Most often diagnosed in adolescence years but does occur
earlier in childhood
o .5% in children and 2% and 4% in adolescents
o higher rates of Social anxiety disorders in females than
males (as cited in Chavira & Stein 2005)
Vulnerability
Increased self-consciousness
Increased demands due to changes in middle school
environment
Children: lower perceptions of cognitive competence, higher
trait of anxiety
Youth: later anxiety, major depressive disorders, substance
abuse disorder, suicide attempts, educational
underachievement


Subtypes
Generalized subtype is the most common form of Social Anxiety
Disorder in children and adolescents (Hofmann, Moscovitch,
Kim, & Taylor, 2004)
Generalized subtype appears to be a more pervasive and
disabling condition than non-generalized subtypes (Chavira &
Stein 2005)








DSM-IV-TR Diagnostic Criteria
A. A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others; with the fears that he/she will act in a way
that will be humiliating or embarrassing.

B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or situationally
predisposed Panic Attack.

C. The person recognizes that the fear is excessive or unreasonable.**
Children and adolescents may fail to recognize their fears as unreasonable and
excessive (attributed to cognitive-developmental limitations), this insight is
required in adults to make the diagnosis.

D. The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.
Diagnostic Criteria cont'd
E. The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person's normal
routine, occupational (academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years,the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted for by another mental disorder.

H. If a general medical condition or another mental disorder is present, the
fear in Criterion A is unrelated to it.
DSM V
A. Marked fear of anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
E.g., social interactions: having a conversation, being observed:
eating or drinking, or performing in front of others: giving a speech.

B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated (e.g., be
humiliated, embarrassed, or rejected) or will offend others.

C. Is the same as "B" in DSM-IV-TR.

D. Remains the same.

E. The fear or anxiety is out of proportion to the actual threat posed
by the social situation.
DSM V
F. Remains the same.

G. The same as "E" in DSM-IV-TR (impairment in functions).

H. The same as "G" in DSM-IV-TR (not due to substance induced).

I. The disturbance is not better accounted for by another mental
disorder.

J. If another medical condition (e.g., stuttering, Parkinson's disease,
obesity, disfigurement from burns or injury is present, the fear,
anxiety, or avoidance is unrelated or is out of proportion to it).

Specify if: performance only; selective mutism.
Video Clip: Social Anxiety Disorder


Rob's story.
http://youtu.be/LFM8M33k2UI


Social Anxiety in School Settings/Home
Peer relationships

Friends
Reluctant to join
group activities
Loneliness
Shy, quiet
Peer victimization
(Siegel, La Greca,
Harrison 2009)

School

Reading aloud
Request for
assistance
Unstructured peer
encounters
Gym activities
Working in groups
Test taking
Eating in the
Cafeteria

Home

Avoidance of
extended family
gatherings,
answering the
phone or doorbell
Refuse to order for
themselves in
restaurants
Lag behind peers
in meeting
developmental
challenges
Social Anxiety Disorder Treatment and
Interventions
Pharmacotherapeutic intervention (Chavira & Stein, 2005)
Selective Serotonin Reuptake Inhibitor (SSRI) - concerns of
possible increased suicidal thinking, suicide attempts, or self-
harms

Cognitive behavioural therapy and Behavioural therapy (Chavira &
Stein, 2005)
Efficacy of these types of therapy are supported
Gains are maintained post intervention
Symptom reduction


Current Issues and Future Directions with
Anxiety Disorders
Hudson and Dodd, 2012
Examined how various factors (child anxiety, behavioural inhibition (BI),
maternal over-involvement, maternal negativity, mother-child attachment and
maternal anxiety), as assessed at age four, predict anxiety at age nine.

Child anxiety, BI, maternal anxiety, and maternal over-involvement were
significant predictors of clinical anxiety

These results can inform intervention:
Important to consider BI in young children; maybe they're not just
shy!
Early intervention is important, even in preschool (growing out of
it is not the case for all children)
Involve mothers; decrease mothers anxiety and include
parenting modules (i.e. overprotection)




Current Issues and Future Directions with
Anxiety Disorders

Walkup et al., 2008
Examined 488 children between age 7-17 with varying anxiety diagnoses.

Over a 12 week period - either received CBT, Sertraline (AKA Zoloft-
SSRI), combination of CBT and Sertraline, or placebo

Results: combination had best outcome, followed by CBT alone, then
Sertraline alone, and least effective was placebo

These results can inform intervention:
Shows that combination therapy offers best chances for positive
outcomes
If we have to choose one, CBT had better outcomes
Can help to inform reluctant parents about meds


Current Issues and Future Directions with
Anxiety Disorders

Children and adolescents alike are ALWAYS using technology these days, why not
use it to effectively treat/manage symptoms of anxiety disorders?

FearShrinker - $5.99 (iPad)
o Fear scale, anxiety symptoms, strategies (i.e. muscle relaxation)

Magical Adventures - $2.99 (iPad)
o Meditations for kids

iCounsellor - $0.99 (iPhone, iPad, iTouch)
o Rating scale, calming activities, changing thoughts, triggers, strategies

Various apps, blogs, websites, forums, e-books

Relaxing music on iPod, etc.


Class Survey:

Diagnosing
Cartoon
Characters


Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Piglet (Winnie the Pooh)?






58%
Generalized
Anxiety
Disorder
Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Gurgle (Finding Nemo)?






47% OCD

32%
Specific
Phobia
Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Charlie Brown ?






37% Social
Phoba

32% GAD
Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Rabbit (Winnie the Pooh)?






53% OCD
Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Marlin (Finding Nemo)?






58%
Separation
Anxiety
Disorder
Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Daffy Duck?






37% GAD

26% OCD
Diagnosing Cartoon Characters: Survey
Results!

What diagnosis would you give to Lion (Wizard of Oz)?






53% GAD

32% Social
Phobia
Diagnosing Cartoon Characters: Survey
Results!

The moral of the story is....

It may be difficult to diagnose if the individual exhibits symptoms of multiple
anxiety disorders

Consultation & collaboration are very important in the field of psychology -
different professional backgrounds, experiences and insights are beneficial for
appropriate diagnoses and subsequent treatment






References
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood Anxiety Disorders. In
Barkley, R. A. & Mash, E. J. Editor (Ed.)., Child psychopathology, 2nd edition, pp. 279-
329. New York: Guilford Press.

American Psychiatric Association (2007). Diagnostic and Statistical Manual of Mental
Disorders: Fourth Edition: Text Revision. Washington, DC.

American Psychiatric Association, The future of psychiatric diagnosis. (2012). DSM-V
Development. Retrieved from http://www.dsm5.org/Pages/Default.aspx

Andrews G, Hobbs MJ, Borkovec TD, Beesdo K, Craske MG, Heimberg RG, Rapee
RM, Ruscio AM, Stanley MA. Generalized Worry Disorder: A review of DSM-IV
Generalized Anxiety Disorder and Options for DSM-V. Depression & Anxiety, 2010;
27:134-147.

AnxietyBC (2012, June 26). Jacob monologue. Retrieved October 12, 2012 from
http://youtube.com/4RSdV9R8wXQ














References
AnxietyBC (2012, June 26). Christine monologue. Retrieved October 12, 2012 from
http://www.youtube.com/watch?v=dgbQ5tnTxto&feature=share&list=ULdgbQ5tnTxt

AnxietyBC (2012, June 26). Rob monologue. Retrieved October 12, 2012 from
http://www.youtube.com/watch?v=LFM8M33k2UI&feature=share&list=ULLFM8M33k2U
I

Beidel, B. C., Turner, S. M., Young, B. J., Ammerman, R. T., Sallee, F. R., & Crosby, L.
(2007). Psychopathology of adolescent social phobia. Journal of Psychopathological
Behavioural Assessment 29:47-54. DOI: 10.1007/s10862-006-9021-1

Chavira, D. A.,& Stein, M. B. (2005). Childhood Social Anxiety Disorder: From
Understanding to Treatment. Children and Adolescent psychiatric clinical (14): 797-818.

Kickthefaucet (2010, April 25). Dr. Oz: What is OCD? Retrieved October 15, 2012 from
http://www.youtube.com/watch?v=_wEU-165NRY

Friends in Canada (n.d.) Friends for life: Preventing and treating anxiety in children.
Retrieved from http://www.friendsinfo.net/ca.htm












References
Grabhorn, R., Stenner, H., Stangier, U., & Kaufhold, J. (2006). Social Anxiety in
Anorexia and Bulimia Nervosa: The mediating role of shame. Clinical psychology and
psychotherapy 13:12-19. DOI: 10.1002/ccp.463

Hofmann, S. G., Moscovitch D. A., Kim, H. J., & Taylor, A. N. (2004), Changes in Self-
Perception during treatment of social phobia. Journal of Consulting and Clinical
Psychology: 72: 588-596

Hudson, J.L. & Dodd, H.F. (2012). Informing Early Intervention: Preschool Predictors of
Anxiety Disorders in Middle Childhood. PLoS ONE 7(8): 1-7.

Maclean, K. L., (2004). Peaceful piggy meditation. Morton Grove, III: Albert Whitman &
Co.

OCD Center of Los Angeles (2012). http://www.ocdla.com/index.html

Siegel, R., S., Greca, A. M. L., & Harrison, H. M. (2009). Peer Victimization and social
anxiety in adolescents: prospective and reciprocal relationship. Journal of Youth
Adolescence (38):1096-1109.








References
Steffloverrsyou82 (2010, Dec 13). Scaredy Squirrel Read Aloud. Retreived
October 12, 2012 from http://youtu.be/DasoZb0cvdE.

Walkup, J.T., Albano, A.M., Piacentini, J., Birmaher,B., Comton, S.N., Sherrill J.T.,
Ginsburg, G.S., Rynn, M.A., McCracken, J., Waslick, B., Iyengar, S., March, J.S., &
Kendall, P.C. (2008). Cognitive Behavioral Therapy, Sertraline, or a Combination in
Childhood Anxiety. The New England Journal of Medicine, 359(26): 2753-2766.