Kimberly Becker, Ph.D.Johns Hopkins Child and Adolescent

Psychiatry

ObjectivesGain knowledge about the prevalence and course of child anxiety

Understand how to recognize symptoms and manifestations of anxiety

Learn how CBT addresses anxiety symptoms

Facts about Anxiety DisordersPrevalence of anxiety disorder: 10%, but often

unidentified and misdiagnosedMean age of onset: 7-15 years old Impairment: academics, attendance, peers,

familiesCourse:

Waxes and wanes1/3 of kids with anxiety improve without treatmentMost adult anxiety disorders have pediatric onset

Comorbidity: very common

ComorbidityHaving more than one disorderAdditional anxiety disorder: 30-80% Mood disorder: 12-60% Externalizing disorder (ADHD, CD,

ODD): 3-60%

Physical FeelingsMuscle tensionHeart palpitationsAbdominal painNauseaFlushed faceHeadachesPerspiration

Anxious youth EXPERIENCE more physical difficulties/complaints

Anxious youth are MORE SENSITIVE to physical sensations

I have a headache and stomachache.

Teacher, can I go see the nurse?

ThoughtsCatastrophizing: blowing things out of proportionOverestimating: expecting the worst will happen“What if…??”

What if the teacher calls on me?

I always get the answer wrong!

Behavior

Avoidance/escape Reassurance-seekingTantrums/disruptive behavior/school refusal

Is anxiety good or bad?

Excessive Persistent Developmentally inappropriateResults in accommodation by othersCauses impairment

When is anxiety a problem?

Anxiety is normal and adaptive. It serves as a natural alarm system to alert us to danger.

Evidence-based AssessmentMultiple informants (e.g., child, parent,

teachers, clinicians, etc.)Multiple methods

Questionnaires Interviews (e.g., ADIS-IV-C)Behavioral observation

Repeated, ongoing assessment throughout treatmentFrequency, duration, intensity, interference

Evidence-Based Treatments for Anxiety Disorders in Children

Medication (SSRIs)Cognitive Behavioral Therapy (CBT)

Child Anxiety Multisite Study (CAMS)Medication effectiveCBT effectiveCombination most effective

Empirical Evidence Summary> 20 controlled trialsResponse: CBT 55-80% Treatment gains maintained – 5-7

years Parent symptoms = poorer outcomes

Goals of CBT for AnxietyReduce anxiety, but not eliminate it

Increase ability to manage and cope with anxiety by teaching skills

Identify and change anxious behaviors (avoidance) and thoughts

Psychoeducation

PsychoeducationGoal: To provide basic facts about anxiety

and its treatment, instill hopeWhen: Session 1, and thereafterKey Points:

Define anxiety: find common languageNormalize anxiety: everyone experiences

it sometimes Externalize anxiety: it is a reaction to

situations…an alarm (true alarm vs. false alarm)

Propose treatment: (1) CBT model, (2) How do you know the difference between true alarm and false alarm? Test it out!

Exposure/Practice: Facing Fears The key component of CBT for

anxietyRationale

Anxiety is partly learned and can be unlearnedLearn that feared consequences do not occur

Fear Ladder Gradually build from easy to hard situations to practice

Step 1

Step 2

Step 3

Step 4

Step 5

Goal!

Sample Fear HierarchySituation RatingGiving speech in front of class 10Giving answer aloud in class 8Asking question aloud in class 6Writing on blackboard in class 4Throwing trash away in class 2

Item SelectionStart exposure/practice by collaboratively

choosing an item that the child will not refuse and that the child will successfully complete

Move up the ladder as the child masters each item

A “good item” is one that provokes anxiety and that the child habituates or gets used to over time

Be creative!

SummaryAnxiety :Normal and adaptiveAffects: thoughts, feelings, behaviorsAnxiety disorders are:CommonMisidentified and under-treatedAmenable to treatmentCBT is:Time-limitedSkill-basedEffective for treating anxiety (50-80%

improvement rate)

Additional ResourcesABCT. ORGACADEMYOFCT.ORGADAA.ORG: convention March 2010, Baltimore

Chorpita, B. F. (2007). Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders. NY: Guilford.

DuPont Spencer, E. DuPont, R., & DuPont, C. (2003). The Anxiety Cure for Kids. New Jersey: Wiley.

Manassis, K. (1996). Keys to Parenting Your Anxious Child. Hauppauge, NY: Barron’s Education Series.

Rapee, R. M., Spence, S. H., Cobham, V., & Wignall, A. (2000). Helping Your Anxious Child. Oakland: New Harbinger Press.