The document discusses childhood anxiety disorders, highlighting characteristics such as excessive and debilitating anxiety, developmental considerations, and symptoms that manifest differently in children compared to adults. It categorizes various forms of anxiety, including separation anxiety disorder, social phobia, generalized anxiety disorder, and obsessive-compulsive disorder, providing DSM criteria and case examples for each. Additionally, it explores the prevalence, etiology, and assessment methods for these anxiety disorders in children.

1. Childhood
Anxiety
Disorders

2. Anxiety
 Anxiety: mood state
characterized by strong,
negative emotion and bodily
symptoms in which an individual
apprehensively anticipates
future danger or misfortune
 Fear: immediate alarm reaction
to current danger
 Anxiety disorder: excessive and
debilitating anxiety with
negative emotion and fear

3. Developmental
Considerations
 Anxiety is an adaptive emotion
that readies children both
physically and psychologically
to cope with danger
 Infancy: loud noises, being
startled, strangers
 Toddlerhood: dark, separation
 School-Age: injury, natural
disasters
 Adolescence: competency-based

4. Developmental
Considerations
 DSM-IV qualifiers for children
 Anxiety may be expressed by crying,
tantrums, freezing, or clinging
 Unlike adults, children are not
required to acknowledge that fears are
unreasonable or excessive
 Difficulties in recognizing symptoms
 Internalizing symptoms less observable
 Internalizing symptoms less aversive
 Children may lack verbal skills to
communicate concerns

5. Anxiety: 3 Interrelated
Systems
 Cognitive
 Anxious thoughts develop in response to
cognitive distortions in the attention,
interpretation, and memory components
of information processing
 Physical
 Brain sends messages to sympathetic
nervous system: fight or flight
response
 Symptoms are excessive in intensity or
duration
 Behavioral
 Action (or inaction) that individuals
take to prevent exposure to feared

6. Case Example
 ““Charlie, now 11 years old , is
entering 6th grade in a middle
school. Each September since
kindergarten the start of school has
always been a struggle for him. This
year his distress escalated with the
added demand of starting in a new
school, and by November he missed
twenty-six days of school. His
academic work has suffered, and his
teachers have sent his assignments
home. Charlie insists that he can't
complete them without his mother's
presence. He worries that something

7. Separation Anxiety
Disorder DSM Criteria:
3+ symptoms  Excessive distress
when separation
from attachment
figure is
anticipated
 Excessive worry
about losing or
possible harm to
figure
 Excessive worry
that an event will
lead to separation
 Reluctance or
refusal to go to
school because of
separation fear
 Excessive fear or
reluctance to be
alone
 Reluctance or
refusal to go to
sleep without being
near attachment
figure
 Nightmares
involving theme of
separation
 Complaints of
physical symptoms
when separation
occurs/is
anticipated

8. SAD:
Clinical Presentation
 Demand parental attention
 Clinging
 Sleep with parents

9. Prevalence, Age of Onset,
Family Characteristics
 Prevalence rate of 2 - 4%
 SAD accounts for 1/2 of all
children and adolescents referred
for treatment of anxiety
disorders
 Occurs as early as preschool age
 No gender differences
 Often occurs in response to some
major stressor

10. Case Example
 ““Corinne's mother tried
everything she could think of
to get her 14-year-old daughter
to join an after-school club or
accept invitations to parties
at classmates' homes. Corinne
insisted that she would rather
stay home and read; she didn't
think she fit in with her
friends any more and didn't
know what to say to them. When
she did venture out with a

11. Social Phobia
DSM Criteria
 Marked and persistent fear of one or
more social or performance
situations in which child is exposed
to unfamiliar people or possible
scrutiny by others
 The child fears he/she will act in a
way that will be humiliating or
embarrassing
 Exposure to situation provokes
considerable anxiety
 Feared situations are avoided or
else endured with intense anxiety

12. Social Phobia:
Clinical Features
 A child with social phobia is
one who displays phobic
responses to one or more social
situations:
 Speaking, eating, or drinking in
front of others
 Initiating or maintaining
conversations
 Speaking to adult authority figures
 Other situations that may elicit
concerns over being
embarrassed/humiliated

13. Social Phobia:
Clinical Features
 In young children, the anxiety
may be reflected in signs of
distress such as crying, throwing
temper tantrums, or becoming mute
and clinging to parents
 In older children, it may be
expressed less dramatically in
terms of trembling hands, a shaky
voice or other obvious signs of
anxiety

14. Social Phobia:
Clinical Features
 Children with social
phobias also experience
anticipatory anxiety
well before actually
confronting these
situation
 Unfortunate cycle
 Anticipate
awkwardness/poor
performance
 Increased anxiety
 Actual awkwardness/poor
performance

15. Social Phobia:
Associated Features
 Children with social phobias can
also show a range of associated
features:
 Being overly sensitive to
criticism
 Having low levels of self-esteem
 Having inadequate social skills
 School performance may be
impaired due to test anxiety and
failure to participate in
classroom activities

16. Social Phobia:
Prevalence
 Relatively rare in the general child
population
 Prevalence estimates of around 1-3%
are suggested by cross-sectional
research
 No gender differences
 Last, et al. (1992) has suggested
that among children referred to an
anxiety disorders clinic, 20% met DSM
criteria for a diagnosis of social
phobia
 Thus, social phobia does not seem to

17. Case Example
 Donna presented to therapy
because she reported that she
was unable to concentrate at
home, at school, and with
friends. She indicated that she
had difficulty falling asleep
at night because her mind was
““constantly racing”” with
thoughts and concerns about
anything and everything. She
described feeling constantly
tense and uptight, noting

18. Generalized Anxiety
Disorder
 Excessive anxiety, unrealistic
worries, and fearfulness, not
related to a specific object or
situation
 Child finds it difficult to control
worry
 Plus one of the following symptoms
 Restlessness or feeling keyed up/on edge
 Being easily fatigued
 Difficulty concentrating or mind going
blank
 Irritability
 Muscle tension
 Sleep disturbance

19. GAD
 ““What if?”” statements
 Marked degree of subjective distress
and excessive worry about a things
including:
 the appropriateness of past behavior
 possible injury or illnesses (to
themselves or others),
 the possibility of major calamitous
events
 their ability to live up to
expectations
 their competencies in various areas
 being accepted by others
 other things related to concerns about

20. GAD: Clinical
Characteristics
 Children tend to be perfectionistic,
worrying about what others will think
of them or their performance
 Engage in excessive approval seeking
and frequent solicitations of
reassurance
 Anxiety level contributes to physical
symptoms:
 headaches, dizziness, shortness of
breath, upset stomach and problems in
sleeping, which may also become a source
of concern and worry


21. GAD Prevalence
 Strauss (1994), in a review of
epidemiological studies, suggests
prevalence estimates of 3% to 5%
with younger children (< 11
years)
 Prevalence rates for adolescents
across studies ranged from 4% -
7%
 GAD is somewhat more frequently
seen in adolescents
 No significant gender differences

22. Case Example
 The mother of 5-year-old Louisa,
says "I go through a routine every
night with Louisa. She always makes
the same requests when I put her to
bed; don't let the bed go up in the
sky. Don't let the moon break the
house. Don't let any alligators,
cows, or snakes into the house.
 Scott, age 4, is afraid of the
banging of the radiator in his room,
the wail of a siren, the noise of
thunder.
 Serena, age 5, and her mother look

23. Childhood Fears and
Phobias
 Childhood fears are
quite common
 Lapouse and Monk (l959),
in a classic survey of 6
to 12 year‑‑ old children,
found that some 43% had
7+ fears
 Childhood fears range
from those related to
very specific and
concrete objects
(e.g.,animals and
strangers) to those
which are more abstract
(e.g., monsters, war,
death).
 Some fears seem to be

24. Childhood Fears:
Developmental Considerations
 Fear of strangers at age 6 to
9 months
 Fear of separation at age 1
to 2 years
 Fear of the dark at around
age 4
 Many fears resolve with time
and do not require treatment
 Some fears are more
problematic and the term
““phobia”” is a more

25. Specific Phobia
DSM Criteria
 Marked and persistent fear that is
excessive and unreasonable, cued by
the presence or anticipation of a
specific object or situation
 Exposure to the phobic stimulus
almost invariably provokes an
immediate anxiety response
 Duration of 6 months
 Types:
 Animal (e.g., snakes)
 Natural environment (e.g., storms)
 Blood-injection-injury
 Situational (e.g., bridges, elevators, flying)
 Other (e.g., loud sounds, choking)

26. Childhood Phobias
 Miller, Barrett and Hampe (l974)
have defined a phobia as a
specific type of fear that is:
 out of proportion to the demands
of the situation
 cannot be explained or reasoned
away
 is beyond voluntary control
 leads to avoidance of the feared
situation
 persists over an extended period
of time
 is not adaptive

27. Childhood Phobias:
Prevalence
 Little investigation of the
prevalance of these
problems in children
 2 - 4% in the general child
population
 Rates on the order of 4%
are found for adolescents
 Rates as high as 6 - 7% are
found in clinical
populations

28. Case Example
 ““Jesse, l0 years old, cleans
his teeth so frequently that he
uses a box of toothpicks each
week and his gums bleed
profusely. Each day he uses a
half box of Q-tips to clean his
ears and a roll of toilet paper
when he goes to the toilet.
When he does his homework,
Jesse can spend an hour on the
same page, erasing and

29. Case Example
 ““Ashley, l6, reports that each time she
leaves a classroom, passes the principal's
office or leaves school, she has to
imagine the number 12 on a clock and say
the words "good luck" to herself. She
reports that she can't stop thinking about
the words "good luck." If she tries to
stop herself from thinking about these
words, she becomes very anxious and
worries that she'll have a heart attack.
In the classroom, she is often frozen in
her seat, unable to respond. She worries
that any decision she makes will result in
something dreadful happening to her
parents. Before going to sleep, she closes
the bedroom door four times, turns the
lights on and off four times and looks out
the window and under her bed twelve

30. Obsessive-Compulsive Disorder
DSM Criteria
DSM IV Criteria
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
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

31. Obsessive-Compulsive Disorder
DSM Criteria
Compulsions as defined by (1) and (2):
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

32. Obsessive-Compulsive Disorder
DSM Criteria
B. At some point during the course of the
disorder, the person has recognized that
the obsessions or compulsions are
excessive or unreasonable. Note: This does
not apply to children.
C. The obsessions or compulsions cause
marked distress, are time consuming (take
more than 1 hour a day), or significantly
interfere with the person’’s 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

33. Common Obsessions and
Compulsions
 Obsessions
 Contamination
 Harm to self or
others
 Need for
symmetry/order
 Religious or
moral concerns
 Sexual or
aggressive
 Lucky or unlucky
numbers
 Compulsions
 Cleaning
 Checking,
counting,
repeating
 Ordering,
straightening
 Praying,
confessing,
reassurance
seeking
 Touching,
tapping, or

34. OCD: Prevalence and Course
 Prevalence
 1-4% of children and adolescents
 Ratio of boys to girls is 2:1 in
childhood; equalizes in adolescence
 80% of all cases have childhood onset
 Course
 Age of onset
 Males 6 - 15 years (peak 10); Females
20 - 29 years
 Onset typically gradual, some acute
 Chronic waxing and waning of symptoms
 Stress exacerbates symptoms
 Estimated that 15% display progressive
deterioration in social & occupational
functioning

35. Case Example
 Dylan, 4 years old, presented to
treatment because his parents were
concerned with his behavior
following a incident in which he was
attacked by a dog. According to his
parents, Dylan would use his toys to
reproduce the incident in play.
Additionally, Dylan avoided going
anywhere near his neighbor’’s house
(where the dog attack occurred) and
became noticeably startled and very
distressed when hearing dog barking.
For the past several weeks, he had
experienced several nightmares in

36. Post-traumatic Stress Disorder
DSM Criteria
 A. Exposure
 Person exposed to a event that involved
threat of harm/death to self or other
 Person’’s response involved intense
fear, helplessness, or horror
 B. Traumatic event is re-experienced
(1+)
 Recurrent and intrusive recollections
(play)
 Recurrent and distressing dreams
 Acting or feeling as if event were
recurring (reenactment)
 Intense distress at exposure to
internal or external cues that resemble

37. PTSD
DSM Criteria
 C. Persistent avoidance of stimuli
associated with trauma and numbing
of general responsiveness (3+)
 Efforts to avoid thoughts/feelings
about event
 Efforts to avoid activities, places,
people related to event
 Inability to recall an important aspect
of trauma
 Markedly diminished interest or
participation
 Feeling of detachment from others
 Restricted range of affect

38. PTSD
DSM Criteria
 D. Persistent symptoms of
increased arousal (2+)
 Difficulty falling or staying
asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response
 E. Duration of symptoms > 1
month

39. Associated Characteristics
of Anxiety Disorders
 Cognitive disturbances
 Interference with academic performance
 Attentional biases (toward threat)
 Cognitive biases (negative spin on
ambiguous situations)
 Physical symptoms
 Sleep
 Aches/pains
 Social and emotional deficits
 Interference
 Low self-esteem
 Loneliness

40. Etiology
 Anxiety arises from a complex
interaction of specific
characteristics related to the child
(e.g., biological, psychological,
and genetic factors) and his or her
environment (e.g., conditioning,
observational learning, family
relations, traumatic events)
 Focus on four most recognized models
 Biological
 Behavioral
 Cognitive

41. Etiology
 Biological
 Genetic Influences
 Biological vulnerability to inherit a
fearful disposition
 Genetic influences account for 1/3 of
variance
 Neurobiological factors
 Within the limbic system, the
behavioral inhibition system is
overactive
 Increased tendency to become over-reactive
and withdraw in response to novel
stimulation

42. Etiology
 Biology, continued
 Neurochemical factors
 Abnormal function of serotonin,
norepinephrine, dopamine, and GABA

43. Etiology
 Behavioral
 Mowrer’’s Two Stage Model of
Conditioning
 Acquisition of fear through classical
conditioning
 An individual associates a threatening
stimulus with a nonthreatening stimulus,
so that the latter by itself triggers
anxiety
 Maintenance of fear through operant
conditioning
 Negative reinforcement is manifested by
avoidance and/or escape learning
 Consequently, without opportunities for

44. Etiology
 Behavioral, continued
 Observational learning
 Children learn about anxiety-provoking
situations by
 observing others experience such
situations or
 by acquiring information through
activities like reading or watching the
news on television

45. Etiology
 Cognitive
 Attentional biases toward threat-related
information
 Selectively attend to information that may be
potentially threatening
 Distorted judgments of risk
 Negative spin on ambiguous/non-threatening
situations
 Lead them to select avoidant solutions
 Selective memory processing
 Tendency to remember anxiety-provoking
cues/experiences
 Perfectionistic beliefs
 Inflated sense of responsibility

46. Etiology
 Ecological
 Bidirectional relationships among
child, family, and other
environmental contributions to
anxiety
 Child temperamental characteristics
(i.e., behavioral inhibition) X
insecure parent-child attachment X
anxious and controlling parenting
styles
 Parental modeling of fear
responses

47. Assessment
 Diagnostic Interviews
 Anxiety Disorders Interview
Schedule for DSM-IV
 Schedule for Affective Disorders
and Schizophrenia for School-Age
Children
 Clinician-administered
 Comprehensive
 Time-consuming and labor-intensive

48. Assessment
 Rating Scales
 Screen for Child Anxiety Related
Emotional Disorders - Revised
(SCARED)
 Multidimensional Anxiety Scale for
Children
 Fear Survey Schedule for Children
–– Revised
 Also, disorder-specific measures
 Quick and easy to administer
 Standardized with good
psychometric properties

49. Assessment
 Observation
 Social-evaluative tasks (e.g.,
classroom presentation)
 Behavioral avoidance to phobic
stimulus
 Parent-child interaction
 Self-monitoring procedures
 Quantify and describe symptoms

50. Treatment
 Behavioral and Cognitive-
Behavioral Treatments have
received most empirical support
 Pharmacotherapy has recently
received promising support
 Selective Serotonin Reuptake
Inhibitors (SSRIs)
 Psychodynamic and Family
therapies have not received
much empirical support

51. Treatment
 Treatments should target the 3
interrelated symptoms
 Physical symptoms
 Rapid heart beat
 Muscle tension
 Insomnia
 Cognitive symptoms
 Distorted perceptions of threat
 Behavioral symptoms
 Avoidance
 Escape

52. Behavioral Therapy
 Exposure Therapy
 Systematic Desensitization
 Relaxation Exercises
 Contingency Management
Strategies
 Modeling

53. Exposure
 Create fear hierarchy
 List of fearful events, rated on
0-100 scale from least to most
anxiety-provoking
 Example: Fear of snakes
 Talk about snakes 3
 See pictures of snakes 5
 Watch movies of snakes 6
 Touch a rubber snake 8
 Go to pet store and hold snake 10
 Gradual exposure: Child confronts
fear

54. Exposure with Response
Prevention
 Obsessive-compulsive disorder
 In addition to exposures, the
child is asked to refrain from
engaging in compulsive rituals
 Example
 Touches floor of public bathroom
(exposure)
 Does not engage in handwashing
(response prevention)
 Proposed therapeutic mechanism
of exposure
 Break the conditioned fear
response

55. Systematic
Desensitization
 3 Steps
 Teach child to relax
 Construct fear hierarchy
 Present anxiety-provoking stimuli
sequentially as child remains
relaxed
 Proposed therapeutic mechanism
 Break the conditioned fear
response, because relaxation is
incompatible with fear response
 Which is better???

56. Relaxation
 Deep breathing
 Imagery
 Progressive Muscle Relaxation
 Proposed therapeutic mechanism
 Increased control over sympathetic
nervous system
 Decreased physiological symptoms

57. Reinforced Practice
 Reinforced
Practice: in
vivo exposure
with a feared
situation or
object and
rewards (e.g.
praise, tokens,
toys, hugs,
etc.) for
approaching and
confronting a
feared situation

58. Modeling
 Filmed modeling
 Live modeling
 Participant modeling

59. Cognitive-Behavioral
Therapy
 In addition to behavioral
strategies……
 Teaches children to understand
how thoughts contribute to
anxiety
 And how to FEELINGS
modify distorted
thoughts to decrease symptoms
THOUGHTS BEHAVIOR

60. Cognitive-Behavioral
Therapy
 Components
 Psychoeducation about nature of
symptoms
 Skill building
 Cognitive restructuring
 Positive self-talk
 Problem solving
 Approach-oriented coping
 Relaxation strategies
 Exposure
 Role play
 Contingency reinforcement: rewards

61. Coping Cat: CBT for Anxiety
 Developed by Phil Kendall at Temple
University
 It is based on basic Cognitive
Behavioral Principles
 Treatment typically takes place
across 16 sessions where the child is
taught:
 how to recognize their physical reactions
and anxious feelings when confronted with
anxiety related stimuli
 to become aware of anxiety-related
cognitions

62. Coping Cat
 The child is also taught to evaluate
their coping responses and apply
self-reinforcement for adaptive
coping behaviors
 Children are encouraged to engage in
both imaginal and in vivo exposure
to anxiety related stimuli, while
using the skills they have been
taught
 In-session and out-of-session
activities are used to give children
opportunities to use skills

63. SAD
 Behavioral components:
 Cognitive components:
 Extra targets: School refusal

64. Social Phobia
 Behavioral components:
 Cognitive components:
 Extra targets: Social Skills
Training

65. Generalized Anxiety
Disorder
 Behavioral components
 Cognitive components
 Extra targets: Reassurance
seeking

66. Specific Phobia
 Behavioral components
 Mostly transient conditions

67. OCD
 Behavioral components:
 Cognitive components:
 Extra Targets: Medications
 SSRIs: Luvox, Paxil, Prozac, and
Zoloft
 Majority of children on medication
improve, but may relapse and need

68. PTSD
 Trauma-focused CBT
1. psychoeducation and parenting
skills
2. relaxation
3. affective modulation: identifying
and coping with negative emotions
4. cognitive strategies
5. trauma narrative
6. in vivo mastery of trauma
reminders
7. conjoint child-parent sessions
8. enhancing future safety and

69.  Any Questions