Childhood Anxiety Disorders

1. Childhood Anxiety Disorders Heidi Clayards Merril Dean Marine McDonnell Jill Schroeder Aleksandra Vujanovic

2. Outline Definitional Considerations Evolution of Anxiety Types and Subtypes of Anxiety Developmental Considerations Epidemiology Etiological Models Comorbidity Screening and Assessment Treatment and Prevention Current Issues and Future Directions

3. Vignette Alex is a 10 year old boy in grade 5. Testing shows Alex is a strong student with better than average grade level academic skills. He can answer questions in class, read well and show orally he understands what is being taught. When Alex is asked to write a quiz or test, or to complete a timed task, problems arise. He becomes loud and rude, he has, on occasion, tipped furniture and tossed books. Generally speaking he will refuse to the do the work or create such a scene that he is removed from class. He has had 5 suspensions for violent behaviour, all centered around work requests. Last week, a support consultant observed the behaviour during a spelling test. She removed him from class, spent some time with him and offered to write the words if he spelt them. Initially reluctant, Alex finally did so. He got 100% in his spelling test.

4. Definitional Considerations • Is anxiety bad? • When is anxiety bad? • What is the difference between normal and abnormal anxiety? • What distinguishes one anxiety disorder from the next? • Focal point of the anxiety and time intervals for the presence of symptoms • Childhood Anxiety disorders are characterized by: • Pattern of excessive worry or uneasiness • Interferes with development and day-to-day functioning at home, school or in the community • Frequency, duration and intensity

5. The Evolution of Anxiety Disorders • Historically, psychiatry ignored fears and anxieties in children and adolescents. Studies were done for purpose of norms and etiology • DSM-I identified phobias as psychoneurotic • DSM-II changed the diagnostic category to phobic neurosis and introduced overanxious reaction as a distinct diagnostic category for children and adolescents

6. Evolution (cont’d) • Overanxious reactions category would be instrumental in understanding childhood and adolescent anxiety • DSM-III and DSM-III-R attempt to define diagnostic criteria for phobias and other anxiety disorders in children. • SAD, avoidance disorder, OAD became the three recognized disorders in children/adolescents on top of the defined adult anxiety disorders • New research discoveries culminated in changes in criteria in DSM-IV.

7. Types and Subtypes • Separation Anxiety Disorder (SAD) • Generalized Anxiety Disorder (GAD) • Social Phobia • Panic Disorder (with or without Agoraphobia) • Agoraphobia • Specific Phobia • Obsessive-Compulsive Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder

8. Separation Anxiety Disorder (SAD) •  “Developmentally inappropriate and excessive anxiety concerning separation from the home or from those whom the individual is attached” • Listed in Disorders usually first diagnosed in Infancy or Early Childhood • Common behaviours observed include avoidance, excessive crying/ fear, somatic complaints, nightmares, sleep disorders • 8 criteria listed in DSM –IV: 3/8 symptoms during a 4 week span confirms diagnosis • CBT is best proven treatment for SAD

9. Generalized Anxiety Disorder (GAD) • Excessive anxiety and worry that causes significant distress for more days than not for 6 months, over a number of domains • Must have one of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance • 3-12% of children diagnosed, average age 8.8-10 • Children show selective attention to negative and threat-related information • High level of physiological arousal

10. GAD – cont’d. • Diminished attentional control – may suggest problems with executive control of attention • Perception of a lack of control increases worry • Cognitive development affects understanding of GAD • Possibility that GAD is over-diagnosed in children

11. Social Phobia (Social Anxiety Disorder) • Marked and persistent fear of social or performance situations where embarrassment might occur; exposure evokes anxiety • Adolescents and adults recognize the fear is unreasonable • Avoidance of situation is preferred, if attending there is marked anxiety • Condition may be generalized or specific • Subtypes include generalized and non-generalized social phobia • Culturally distinct

12. Social Phobia (Social Anxiety Disorder) What happens when individuals with social phobia enter feared situations? Clark and Wells’ (1995) cognitive model of social phobia

13. Other Anxiety Disorders

14. Other Anxiety Disorders

15. Developmental Considerations • Some anxiety is normal so much be careful to determine if anxiety is age appropriate • Lack of communication skills means younger children cannot define or explain their feelings • Anxiety can manifest as somatic symptoms

16. Developmental Considerations

17. Developmental Considerations

18. Epidemiology • Waddell et al(2002) student suggests 6.4% of children experience Anxiety Disorders at any one time. • The Costello et al (2003) study – 3% of all children affected by anxiety disorders – 3 month point 9% - estimated occurrence for children of 1 event by age 16 was 3X higher • Equal number of boys and girls when young; by adolescence, more prevalent in girls. • Left untreated there are short and long term consequences

19. Etiological Models Genetics • twin studies indicate childhood anxiety tends to aggregate in families • Eley & Gregory (2004) “typically genetic influences account for roughly 30%, environmental 20% and non-shared environment the remaining 50% of the variance in childhood anxiety” (74) • Heritability may be 50% for OCD • General versus specific genetic contributions

20. Etiological Conceptualizations • Theoretical Models • Genetic / Biological Models • Integrative Models

21. Theoretical Conceptualizations

22. Biological / Genetic Conceptualizations

23. Integrative Conceptualizations: Triple Vulnerabilities – Stress Diathesis Model

24. Integrative Conceptualizations – The Tripartite Model of Anxiety and Depression

25. Comorbidity among Anxiety Disorders • Concurrent mental health problems such as depression and anxiety disorders are common. • Highest comorbidity with depression is anxiety disorder. • Childhood Anxiety disorders manifest first, before depression • Separation Anxiety often leads to adult onset Panic Disorder

26. Screening and Assessment • No definitive biological or psychological test • Diagnosis made using reports from a variety of sources (parents, teachers, medical professionals, counsellors, etc) • Ideally uses a multi-disciplinary team • Recommend triangulation including at least two different instruments or measures.

27. Screening and Assessment

28. Screening and Assessment

29. Treatment and Prevention • Protective factors include: • Emotional stability • Secure attachment • Positive parenting • Ability to use effortful control • Perceived control • Self-esteem and self-efficacy • Coping strategies • Defense mechanisms • Emotional regulation • Social supports

30. Treatment and Prevention • BC study found (Waddel, Hua, Godderis, McEwan and Wong, 2004) • Most efficacious treatment for most anxiety disorders is CBT • Most efficacious treatment for specific phobias is graded exposure • Most efficacious anxiety prevention program uses cognitive-behavioral techniques in school settings (i.e. Friends Program).

31. Prognosis • Early onset/lack of treatment concerns • Extension into adulthood with comorbid disorders • Non-treated disorders will predict adult anxiety and depression; also will predict child onset of substance abuse, hospitalization and suicide attempts

32. Current Issues & Future Directions Significant DSM V Changes/Improvements - Will include severity scales under a number of subtypes to determine relative severity - Separation Anxiety Disorder early onset (before 6) deleted provides examples of types of worry change wording for better application for adults - OCD moving to its own Disorder

33. Current Issues and Future Directions Significant DSM V Changes/Improvements - Panic Disorder with and without Agorophobia and Agoraphobia without History of Panic Disorder agorophobia becomes its own codable disorder that may be comorbid to Panic Disorder - PTSD and Acute Stress Disorder moving to its own Disorder - Social Phobia (Social Anxiety Disorder) returning to the name Social Anxiety Disorder

34. Current Issues and Future Directions • SAD provides examples of types of worry; changes wording to make it a more applicable potential diagnosis for adults

35. Recommended Readings/Viewing • Kendall, P.C., Compton, S.N., Walkup, J.T., Birmaher, B., Albano, A.M., Sherrill, J., …Piacentini, J. (2010). Clinical characteristics of anxiety disordered youth. Journal of Anxiety Disorders, 25, doi:10.1016/j.janxdis.2010.01.009 • Manassis, K., Hudson, J.L., Webb, A. & Albano, A.M. (2004). Beyond behavioral inhibition: Etiological factors in childhood anxiety. Cognitive and Behavioral Practice, 11, 3-12. Downloaded University of Calgary, September 29, 2011. • Pediatric Playbook – Anxiety – Dr S.. Goldman, Children’s Hospital, Boston http://youtu.be/xHzrcGZyEtc • Dr. Arlene Young, Simon Fraser University http://www.youtube.com/watch?v=loRC9T8qUGk&feature=youtu.be

36. Exit Card • In the chat box for the class, enter one point regarding either: • What was new to you • Something that is unclear that you would like clarification on • A moment of epiphany

37. References • Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum. • Anderson, E. R., & Hope, D. A. (2008). A review of the tripartite model for understanding the link between anxiety and depression in youth. Clinical Psychology Review, 28(2), 275-287. doi:10.1016/j.cpr.2007.05.004 • Albano, A.M., Chorpita, B.F., & Barlow, D.H. (2003). Childhood Anxiety Disorders in E.J. Mash & R.A. Barkley (2003). Child Psychopathology, 2nd ed. (pp. 279-329). New York: Guilford Press. • Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007). Predicting children's anxiety from early attachment relationships. Journal of Anxiety Disorders, 21(8), 1061-1068. doi:10.1016/j.janxdis.2006.10.013 • Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.

38. References • Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., et al. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 545–553. • Brown, T., & Barlow, D. (2005). Dimensional versus categorical classification of mental disorders in the fifth edition of the diagnostic and statistical manual of mental disorders and beyond: Comment on the special section. Journal of Abnormal Psychology, 114(4), 551-556. doi:10.1037/0021-8743X.114.4.551 • Brumariu, L. E., & Kerns, K. A. (2008). Mother–child attachment and social anxiety symptoms in middle childhood. Journal of Applied Developmental Psychology, 29(5), 393-402. doi:10.1016/j.appdev.2008.06.002 • Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M. R., Hope, D. A. and Schneier, F. R. (Eds.), Social Phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press.

39. References • Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100(3), 316-336. doi:10.1037/0021-843X.100.3.316 • Costello, E.J., Egger, H.L., & Angold, A. (2004). Developmental epidemiology of anxiety disorders. In T.H. Ollendic & J.S. March (Eds.). Phobic and anxiety disorders in children and adolescents: A clinicians guide to effective psychosocial and pharmacolgoical interventions. (pp. 61-91). New York:Oxford University Press. downloaded October 2, 2011 from University of Calgary ebook collection. • Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A.(2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837–844. doi:10.1001/archpsyc.60.8.837. • Dallaire, D. H., & Weinraub, M. (2007). Infant–mother attachment security and children's anxiety and aggression at first grade.. Journal of Applied Developmental Psychology, 28(5-6), 477-492. doi:10.1016/j.appdev.2007.06.005

40. References • De Bolle, M., & De Fruyt, F. (2010). The tripartite model in childhood and adolescence: Future directions for developmental research. Child Development Perspectives, 4(3) 174-180. doi: 10.1111/j.1750-8606.2010.00136.x • Eley, T.C. & Gregory, A.M. (2004). Behavioral genetics. In T.L. Morris & J.S. March (Eds.). Anxiety disorders in children and adolescents. (pp 71-97). New York:Guilford Press. • Guy, W. (1976). The clinical global impression scale. The ECDEU assessment manual for psychopharmacology—revised (Vol DHEW Publ No ADM 76-338), Rockville, MD:  U.S. Department of Health, Education, and Welfare, Public Health Service, Alcohol Drug Abuse, Mental Health Administration, NIMH Psychopharmacology Research Branch, Division of Extramural Research. pp. 218–222. • Higa-McMillan, C. K., Smith, R. L., Chorpita, B. F., & Hayashi, K. (2008). Common and unique factors associated with DSM-IV-TR internalizing disorders in children. Journal of Abnormal Child Psychology, 36(8), 1279-1288. doi:10.1007/s10802-008-9250-8

41. References • Kiff, C. J., Lengua, L. J., & Bush, N. R. (2011). Temperament variation in sensitivity to parenting: Predicting changes in depression and anxiety. Journal of Abnormal Child Psychology. doi 10.1007/s10802-011-9539-x • March, J., Parker, J., Sullivan, K., Stallings, P., & Conners, C. (1997). The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 554–565. • Muris, P.R. (2007). Normal and abnormal fear and anxiety in children and adolescents. Burlington, MA:Elsevier Science and Technology. Downloaded October 2, 2011, from University of Calgary ebook collection. • Muris, P., & van der Heiden, S. (2005). Anxiety, depression, and judgments about the probability of future negative and positive events in children. Journal of Anxiety Disorders, 20(2), 252-261. doi:10.1016/j.janxdis.2004.12.001 • Roelofs, J., Meesters, C., ter Huurne, M., Bamelis, L., & Muris, P. (2006). On the links between attachment style, parental rearing behaviors, and internalizing and externalizing problems in non-clinical children. Journal of Child and Family Studies, 15(3), 319-332. doi:10.1007/s10826-006-9025-1

42. References • RUPP Anxiety Study Group. (2002). The Pediatric Anxiety Rating Scale (PARS): development and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1061–1069. • Shamir-Essakow, G., Ungerer, J. A., & Rapee, R. M. (2005). Attachment, behavioral inhibition, and anxiety in preschool children. Journal of Abnormal Child Psychology, 33(2), 131-143. doi:10.1007/s10802-005-1822-2 • Shelton, R. C. & Hunt, A. J., 2008. Anxiety disorders. In S. H. Fatemi, & P. J. Clayton (Eds.), The medical basis of psychiatry (pp. 133-159). Totowa, NJ: Humana Press, Inc. doi:10.1007/978-1-59745-252-6 • Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. Boulder, CO: Graywind Publications Incorporated • van Brakel, A. M. L., Muris, P., Bögels, S. M., & Thomassen, C. (2006). A multifactorial model for the etiology of anxiety in non-clinical adolescents: Main and interactive effects of behavioral inhibition, attachment and parental rearing. Journal of Child and Family Studies, 15(5), 568-578. doi:10.1007/s10826-006-9061-x .

43. References • van Brakel, A. M. L., Muris, P., Bögels, S. M., & Thomassen, C. (2006). A multifactorial model for the etiology of anxiety in non-clinical adolescents: Main and interactive effects of behavioral inhibition, attachment and parental rearing. Journal of Child and Family Studies, 15(5), 568-578. doi:10.1007/s10826-006-9061-x • Waddell, C., Hua, J., Godderis, R., McEwan, K. & Wong, W. (2004). Preventing and treating anxiety disorders in children and youth. Vancouver, BC:Children’s Mental Health Policy Research Program. Downloaded October 1, 2011, from University of Calgary ebook collection. • Waddell, C. Offord, D.R., Shepherd, C.A, Hua, J., & McEwan, K. (2002). Child psychiatric epidemiology and Canadian public policy-making: The state of the science and art of the possible. Canadian Journal of Psychiatry, 47, 825-832. • Wood, J. J., McLeod, B. D., Sigman, M., Hwang, W., & Chu, B. C. (2003). Parenting and childhood anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 44(1), 134-151. doi:10.1111/1469-7610.00106

44. References • Wood, J. J., McLeod, B. D., Sigman, M., Hwang, W., & Chu, B. C. (2003). Parenting and childhood anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 44(1), 134-151. doi:10.1111/1469-7610.00106