Childhood Anxiety

Thomas Clay, MSW, Terry LaRue, MSW

December, 2014

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The Objectives for Today• Provide an overview of

Anxiety Disorders• Provide evidence and

summarize specifically childhood anxiety

• Discuss effective practices and interventions

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The Discussion is On Three Levels

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Anxiety Disorders

ChildhoodManifestation

Social Phobia

Table of Contents• Overview of anxiety disorders• The problem of childhood anxiety

– emphasis on social anxiety disorder (SAD)

• Selection of Literature• Best practice knowledge and guidelines• How to conduct an effective practice• What we still need to know

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I. Overview

1) Separation Anxiety

2) Selective Mutism

4) Social Anxiety Disorder (SAD)

3) Specific Phobia

5) Panic Disorder6) Agoraphobia7) Generalized Anxiety Disorder (GAD)8) Substance/Medication-Induced Anxiety

The DSM-5 Includes 8 Primary Anxiety Disorders

How clinicians differentiate:

1) Types of objects or situations…

…that induce fear, anxiety, oravoidance behaviors

2) and the associated cognitive ideation

The DSM-5 lists the disorders in order of developmental time periods Source: APA, 2013Developmental

Period

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The Key Characteristics of Anxiety Disorders

Fear Anxiety AvoidantBehaviors

Emotional response to to a (real or perceived) imminent threat

Anticipation of future threats

Pervasive in nature

Fight or flight – escape behavior

Autonomic responsesFight or flight

Muscle tensionVigilance

Overlap but distinct differences – time and responseSource: Allen, Rapee, Sandberg, 2008

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Differential Diagnosis for SAD

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All other anxiety disorders +

Other Mental Health ChallengesMajor Depressive DisorderBody Dysmorphic DisorderOppositional Defiant DisorderAvoided Personality DisorderAutism Spectrum DisorderDelusional DisorderSchizophrenia

Normative ShynessOther Medical Conditionse.g. obesity

How clinicians differentiate:1) Types of objects or situations…

…that induce fear, anxiety, oravoidance behaviors

2) and the associated cognitive ideation

+Source: Lewinsohn, Rhode & Seeley, 1995

There are Many Known Scales to Assess Anxietyand to Measure the Effectiveness of Treatment

Beck Anxiety Inventory

State-TraitAnxiety Inventory

High Reliability and Validity Empirically Tested

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Multidimensional Anxiety Scale for

Children

Source: Nauta, Scholing, Rapee & Abott (2004)

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II. The Problem of Childhood Anxiety

Anxiety is a Significant Challenge for Many Children

• Research suggests anxious children:– Marked impact on child development– Miss out on key social experiences– Commonly comorbid with other disorders

• Anxiety has the highest prevalence rate of all mental health challenges for children:– Research suggests that approximately 2.5 to 5% of children and

adolescents meet the DSM guidelines for an anxiety disorder at any given time

– Females have twice the risk than males to develop disorders Source: Rapee, Schniering & Hudson, 2009

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Childhood Anxiety Has a Moderate to High Impact on Functioning

• Largest impact area is family processes

• Functioning in school and with peers is significantly impacted

• Positively associated with victimization (bullying)

• Negatively associated with popularity and social competence

• Childhood anxiety often continues to impact functioning into adulthood

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Source: Rapee, 2012, 2013

Childhood Anxiety Has an Impact on Brain Integration

• Dr. Daniel Siegel defines well-being as:– “the vertical and horizontal integration of widely separated

areas in the brain”

• Stress causes cortisol to be released

• Excessive stress impacts the: – development of areas of the brain that link widely separated

areas

• Three primary areas involved– – the prefrontal area, the hippocampus, and the corpus callosum

• Cortisol can slow the growth of synapses, kill synapses, and can kill whole neurons

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Source: Siegel, 2010

Research Strongly Suggests that the Etiology of Childhood Anxiety Develops through Several Paths

Genetic/FamilyInfluence

Anxious Belief Systems

Parenting Style and Reactions

Life Events e.g. divorce

Avoidance Behaviors

Main Fears Developed that Drive the AnxietySource: Rapee, 2013

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Demographic Correlates

• Feature most significantly related is gender:– female 2X (Rapee, 2012)

• Few consistent demographic correlates (except gender) (Drake, Ginsburg, 2012)– anxiety does not appear to be consistently related to family size,

parents marital status, education level, or ethnicity

• The main exception is a study that indicated a small negative association with socio-economic status (Cronk et al., 2004)

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Risk Factors

• Poor pre-natal care has been associated with anxiety (Lewinsohn, Rohde & Seeley, 1995)

• First degree relatives with an anxiety disorders– increase likelihood of development 6X (Rapee, 2012)

• Children most at risk for social anxiety disorder:– include disabled, obese and children with low-self esteem and /

or social awkwardness (Hettema, Neale & Kendler, 2001)

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Gregory and Eley (2007) Twin Studies

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• Estimated that genes account for approximately 30% of variance

• Shared environments:– (e.g. family environment approximately

20% of variance)

• Non-shared environments:– (school, peer groups) and error explain

the remaining 50%)

Research with Toddlers Show Four Main Prognostic Factors

• Parental modeling• Parental overprotection• Parent distress/anxious parents• Personality inhibition/withdrawn

(temperament)

Parenting Style and Reactions

Source: Edwards et al., 2009

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Descriptive Study Using Three and Four Year Old Children

Parenting Style and Reactions

800 Parents Self-Reported Over Time

ParentDistress

ChildInhibition

OverProtection

ChildAnxiety

Age 3 Age 4

Source: Edwards et al., 2009

OverProtection

ChildAnxiety

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Sample Experiment

Modeling of Fear to Novelty in Toddlers

Source: Gerull et al.,2002 Parenting Style and Reactions

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Sample Experiment

Child Report at Age 7

Parenting Style and Reactions

Source: Gerull et al.,2002

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Sample Experiment

A Sample of Theories that Inform the Problem of Childhood Anxiety

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• Etiological studies point to familial • Erikson’s life stage theory• Social learning theory – learning through

modeling• Attachment theory – neurological factors• Cognitive behavioral theory – thought distortions• Empowerment theory – social acceptance

Source: Rapee, 2013

Deleterious Effects of Anxiety• Internalizing affect – higher probability for

women• Externalizing affect – more males impacted• Social functioning impairment• Marital status and intimacy issues• Overall employability• Educational obtainment

Source: Rapee, 2012, 2013

It’s importantto help childrenmanage anxietyas they progress to adulthood.

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The DSM-5 Symptoms for Social Anxiety Disorder (SAD) Include…

• Excessive anxiety across a variety of social domains:– e.g. meeting new people, being observed in front of others, eating in

groups, everyday dyadic conversations

• Fear is present in almost all social situations and has persisted for at least six months

• One has a heightened sense of being evaluated by others:– humiliating/embarrassing; will lead to rejection or will offend others

• Clear demonstration of avoidance behaviors relative to social situations

Source: APA, 2013

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The Clinical Presentation of Childhood Anxiety

• Excessive distress out of proportion to the situation

• Repetitive reassurance questions: “what if”• Anticipatory anxiety – often weeks ahead• Perfectionism and overly self-critical• Demonstrating excessive avoidance• Excessive time consoling child about distress

in ordinary situationsSource: The Children’s and Adult Center for Anxiety

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Comorbidity Rates are Significant

• Research suggests that 40-50% of anxious children meet criteria for more than one anxiety disorder– Likely reflects common risks and maintenance (Rapee, 2012)

• High correlation with depression (Brady & Kendall, 1992)– anxious children 8 to 29 times the risk for depression

• Population studies have confirmed strong overlap between anxiety and depression (Angold et al., 1999)

• Unlike adult anxiety, childhood anxiety does not have a strong correlation to substance abuse

Source: Rapee, Schniering & Hudson, 2009

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Development and Course

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Researchers use homotypic vs. heterotypic continuity as relevant constructs for childhood anxiety:

•Homotypic refers to a future occurrence of the same constellation of symptoms:– Medium age of onset 13 years old (SAD)– Research suggests moderate to strong homotypic continuity in anxious children.

The disorder continues as they move through life stages.

•Heterotypic continuity refers to developing other additional disorders later in life:– Research suggests a strong relationship with later depression and substance abuseSource: Rapee, Schniering & Hudson (2007)

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III. Selection of Literature

Search Procedures

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• Searched USC libraries databases, Google Scholar, National Institute of Health, PsychInfo, ProQuest Psychology Journals, Family & Society Studies Worldwide, National Registry of Evidence Based Programs and Practices (SAMSHA)

• A sample of search terms and phrases:– “evidence based practice for childhood anxiety”– “prevalence of childhood anxiety”– “diagnosing childhood anxiety”

Availability, Quality and Selection of Literature

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• A significant amount of research exists:– the large portion is peer reviewed, random controlled

experiments – we also reviewed 4 meta-analyses

• New research being added and an increased emphasis since early 1990’s

• However, a wide range of prevalence rates• Also, some gaps in the literature

– (to be discussed later)

Source: Rapee, 2013

Key Points from the Existing Literature

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• Anxiety in children is common (high prevalence)• The mental health challenge has moderate life impact• Twin studies demonstrate nature and nurture• Child temperament is a key factor in the development of

anxiety• Strong evidence for CBT as an efficacious treatment • CBT + pharmacology considered extremely effective

– 76% reduction of symptoms after 3 months

Sources: Rapee, 2013/ Rapee, Schiering & Hudson, 2009/ Lewinsohn, Rohde & Seeley, 1995

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IV. Best Practice Knowledge and Guidelines

Treating Childhood Anxiety

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• Biopsychosocial assessment– parent and child if possible– ADIS-CT

• Understand relevant cultural issues– e.g. individualistic vs. collectivism

• Treatment of choice is CBT– effective in an individual or group setting– depending on severity - pharmacology

Source: Rapee, 2013

The Most Empirically Supported Programs Fall Into Two Categories

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Cognitive-Behavioral Treatment

Skills Based

Assertiveness trainingSocial skillsProblem solvingRelaxationGradual Exposure

PsychoeducationCognitive restructuringAffect recognitionEn vivo role playing(parents usually involved)

General idea is to identify the anxiety and apply skills to gradually face their anxiety Source: Rapee, 2013

New Ways of Thinking About and Dealing with the World

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Efficacy of Programs for Childhood Anxiety

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ProgramName

Sample N= PostTest

FollowUp

Quality Rating

Adolescents Coping with Emotions 14-15 years 629 0.04 -0.10(12) 3Aussie Optimism Adolescent 189 0.20 0.24(6) 2Cool Kids Program 8-11 years 91 0.35 0.57(4) 2Penn Resiliency Program 8-16 years 44 0.07 0.63(6) 2Stress Inoculation Training Adolescent 48 0.76 1.03(1) 1

A sample of programs

Prevention and early intervention CBT programs for anxiety

Source: Neil & Christensen, 2009

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An Overview of an Evidence Based Practice

The Cool Kids Program Helps Children Manage their Anxiety

• Developed at Macquarie University, Sydney, Australia– Centre for Emotional Health lead by Dr. Ronald Rapee– based on scientific research and clinical feedback

• Delivered in group or individual format• Generally targeted to children ages 6-17 • Fully supported with manuals/materials

Source: Rapee et al., 2009

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The Cool Kids Program is Designed for Several Types of Childhood Anxiety

Generalized Anxiety

Social Anxiety

Panic Disorder

Separation Anxiety

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Source: Rapee et al., 2009

The Goals of the Cool Kids Program

• Reduce symptoms of anxiety• and associated family distress and avoidance

• Improve peer relationships and self-efficacy• Increase school engagement and

performance• Ultimate goal: improve overall functioning

and reduce risk of adulthood anxiety

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Source: Rapee et al., 2009

The Cool Kids Program Uses a Modular Intervention Approach

Psychoeducation

Homework

Parenting Skills

Cognitive Restructuring

Relaxation Techniques

Social SkillsRole Playing

Problem Solving Skills

Modeling

Assertiveness

Coping SkillsSituational Exposure

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Empirical Support for the Cool Kids Program is Strong

• Efficacy of the overall Cool Kids program– effectiveness of adaptations

• Scientific Rating Scale (SAMSHA) - 3 (Promising Research Evidence)

• Child Welfare System Relevance Level= Medium

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Source: SAMSHA

Empirical Support for the Cool Kids Program is Strong (Cont.)

• Cool Kids scored in the top 10 of all programs (SAMSHA)

• Cool Kids program at post-test 4-month effect size (.57)

• Programs specifically studying ages 7-11, Cool Kids tied for 1st

• Why did we choose the program?

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Source: Rapee et al., 2009

The Program is Extremely Culturally Adaptable(other programs we researched were limited)

Low Cost

Target Symptoms

Cultural adaptability-Translated into +10 languages-Delivered in over +25 countries

(Asia, Europe, Latin America, U.S.)

Multiple Settings – +500 sites to date (e.g.schools, churches)Effective various various demographic groups

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Books, Manuals, Translated Materials, CD’s Modular Approach

https://accessmq.com.au/catalog

Evidence Based PracticesAlternative Treatment

• EMDR – proven efficacious for a wide range of disorders, including anxiety, panic attacks, and social phobias

• Delivery method(s) – especially via bibliotherapy– low cost, minimal therapist contact– empirically tested:

• Randomized controlled test (bibliotherapy, standard group, or wait list)

• Bibliotherapy demonstrated benefit relative to standard group and wait list

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V. How to Conduct Effective Practice

Salient Factors that Impact Treatment Outcomes

• Type of assessment tool used and outcome measure emphasized– Diagnostic status, clinician ratings, child self-report, parent

report– Research suggests more positive outcomes with child self-

report

• Parent anxiety status and parenting style• Comorbidity – additional challenges Source: Rapee, Schniering & Hudson (2007)

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Child Anxiety Life Interference Scale (CALIS)

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Source: Lyneham, Sburlati, Abott, Rapee, Hudson, Tolin & Carlson, 2013

• Provides a comprehensive, reliable, and valid self-report– measures symptom presence and interference– 24 questions, 20 min., self graded

• By focusing on impairment:– align better with parent and child– better prediction of treatment outcome

• Designed to be used in conjunction with Cool Kids program

Child Anxiety Life Interference Scale (CALIS)

High Reliability – Cronbach’s Alpha on child’s life - .80

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Source: Lyneham, Sburlati, Abott, Rapee, Hudson, Tolin & Carlson, 2013

Cronbach’s Alpha for mother’s report - .88Cronbach’s Alpha for father’s report - .89

High Validity – Moderate to strong positive correlations for self-reported internalizing symptoms Moderate positive correlations between anxiety interference scores and externalizing symptoms

How to Conduct Effective PracticeActing Upon the Principles of CBT

• Sessions 1-2 – psychoeducation– “name it and tame it” cognitive reactions

• Thematic anxiety triggers worksheet• Sessions 3-5 – social skills training and cognitive

rehearsal• Relaxation training• Session 5-8 – imaginal exposure and measuring

anxiety symptoms

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Sources: Beck, 2011/ Ledley, Marx & Heimberg, 2010

Efficacious Medications for Childhood Anxiety

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• First line of psychotropic treatment for childhood anxiety is SSRI’s (low doses)– help regulate reuptake of key neurotransmitters– e.g. Paxil, Zoloft

• Generally well tolerated• Stronger drugs used in extreme cases – e.g. Xanex• Approved by FDA for children• Recommended -always be in conjunction with CBT

Source: Blanco, Schneier, Liebowitz, 2012

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VI. What We Still Need to Know

Future Knowledge Needed

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1. A common methodology to measure prevalence 2. A comprehensive understanding of factors leading to

childhood anxiety (Rapee, 2013)3. Additional understanding of gender differences4. The significance of parent involvement in treatment:

1. limited studies show little effect (Barrett, 1998)

5. Stronger comorbidity research6. The mechanisms by which parent anxiety impacts the child’s

anxiety and treatment outcomes (Rapee, 2012)

Trends for Future Research

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1. Stress is being studied extensively as part of several “brain initiatives”

2. Research is being conducted that focuses more on prevention strategies for entire populations e.g. school districts

3. Alternative delivery methods are being experimentally tested

Sources: Rapee, 2013/ Rapee, Schiering & Hudson, 2009/ Lewinsohn, Rohde & Seeley, 1995

Knowledge and Skills Needed for Effective Practice

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• Specialized training for assessing childhood anxiety and using scales – ADIS-C, CALIS, MASC

• CBT training and familiarity with Cool Kid modules• Training in delivering social skills training• Additional training e.g. play therapy, role play and

thematic psychology

Important Cultural Considerations

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• Harper & Lantz (1994) outlined eight important variables when working with anxious clients:– Understanding and respect for client’s worldview– Emphasis on hope and empowerment– Recognition of cultural rites designed to aid in transitions– Cultural norms regarding the expression of emotions– Allowing client to apply personal “meaning to their experience”

• However, respect for individual qualities and experience is vital to develop an effective therapeutic relationship

Source: Harper & Lantz (1994)

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According to the U.S. National Institute on Mental Health, an estimated 50% of school aged children who present with some form of mental illness, such as social anxiety, do not receive treatment (2010).

Source: Rapee, 2013

Reducing Child Anxiety is Challenging and Important Work

What We Covered Today• Provided an overview of

Anxiety Disorders• Provided evidence and

summarize specifically childhood anxiety

• Discussed effective practices and interventions

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