Child and Adolescent Clinical Psychology: Anxiety Disorders

Treatments for anxiety disorders in children and adolescents. Oxford FHS exam.

Kessler et al., 2005

Lifetime prevalence and age of onset distributions of DSM 4 disorders.

• Lifetime prevalence of ADs: 28.8%.

• Median age of onset: 11 years.

• SAD is the third most common mental health disorder

Polanczyk et al., 2015

Worldwide prevalence of mental disorders in children and adolescents: 6.5% anxiety disorders

Creswell et al., 2020

greatest predictors of child ADs:

• child temperament (behavioural inhibition associated with higher likelihood of anxiety)

• presence of an AD in a parent, increasing vulnerability both through genetic factors and also modelling anxious behaviours

Yap & Jorm, 2015

Parental control is the parenting behaviour that seems to have the most robust and consistent effect on child anxiety, accounting for approximately 8% of the variance

Lawrence et al., 2019

Children are at significantly higher risk of having an anxiety disorder if a parent also has an anxiety disorder

De Rosnay et al., 2006

Experiment:

• infants observing mother interacting with stranger

• either demonstrating anxious or non-anxious behaviour

• Infants then interacted with stranger

Thirlwall & Creswell, 2010

Experiment:

• mothers trained to engage in either controlling or autonomy-granting behaviours when interacting with their child preparing a speech.

• Significantly moderated by child trait anxiety, but children of more controlling mothers reported more negative feelings

Creswell et al., 2013

Observational study of anxious and non-anxious mothers interacting with their anxious children

• anxious mothers acted more anxiously and held more negative expectations

• but this was moderated by how much anxiety the children expressed

Hudson et al., 2009

Mothers with clinically anxious vs non-clinical children.

Mothers were observed interacting with a child (not their own) from the same group as their own, and a child from the other group, whilst completing a task where the child had to prepare and deliver a speech.

All mothers were more involved with anxious children.

Mothers of anxious children were less negative when interacting with the non-anxious children.

James et al., 2020

CBT currently recommended as evidence-based treatment approach for child ADs.

• Better treatment outcomes than alternatives, TAU, or waitlist.

• However, around half of young people still meet the diagnostic criteria for their primary AD post-treatment, and this is even higher when translated into a community setting

Thirlwall et al., 2018

RCT of guided parent-delivered CBT. Full, brief, or WL. Full produced superior diagnostic outcomes compared with WL at post-treatment, whereas brief did not.

Creswell et al., 2023

Review of RCTs for parent-led CBT. Is a promising option for increasing access to therapy.

• Two core principles of empowering parents and providing opportunities for new learning for children.

Steinberg, 2005

Executive skills required for goal-directed regulation of behaviour and emotion not yet fully developed in adolescence.

Early adolescents in particular experiencing intense emotions without yet having the cognitive capacity to regulate them independently.

McLaughlin et al., 2015

Adolescence is a time of increased emotional reactivity, with a greater intensity of both positive and negative emotions being experienced.

Young et al., 2019

Development of emotional regulation skills follow a linear trajectory throughout adolescence.

Schäfer et al., 2017

Young people who report using more adaptive emotional regulation strategies, such as cognitive reappraisal, and less maladaptive emotional regulation strategies, such as avoidance or rumination, report lower symptoms of both anxiety and depression

McLaughlin et al., 2022

Emotional reactivity in adolescents is particularly heightened during social situations

Rosen et al., 2018

Social and emotional information becomes particularly salient, with greater activity in the anterior cingulate and anterior insula when viewing images of others’ emotions

Waite & Creswell, 2014

In the children and adolescents referred for treatment, the proportion of adolescents with SAD as their primary diagnosis was much higher than the proportion of children.

Adolescents with a primary anxiety disorder had significantly higher self and clinician-rated anxiety symptoms and had more frequent primary diagnoses of SAD, diagnoses and symptoms of mood disorders, and irregular school attendance

Baker et al., 2021

with only just over a third in remission post-treatment, there is a clear need to develop more effective treatments for adolescents. need to look at disorder specific treatments

Plaisted et al., 2021

‘critical ingredient’ of CBT is behavioural exposure.

some support in young people of strategies to optimise exposure: dropping safety behaviours, discouragement of avoidance (i.e., from therapists and parents), and the use of homework between sessions.

Parents have the capacity to influence efficacy of exposure, through modelling of exposures and coping behaviours, and facilitating exposures for the child

Whiteside et al., 2016

use of exposure in clinical practice is limited (When surveyed, only 5% of 331 therapists working with child anxiety disorders endorsed exposure-focused treatment)

Whiteside et al., 2020

meta-analysis of RCTs for child anxiety disorder CBT, assessing the differences in treatment components included study protocols.

• Although almost all (98.2%) of the included studies involved exposure, over 20% of these did not include in-session exposure

• and only around a third of the sessions within a treatment course involved exposure.

• significant associations between the inclusion of relaxation in treatment and smaller effect sizes

Ale et al., 2015

comparing effects of CBT for child ADs with effects of ERP for child OCD.

ERP significantly more effective.

Notably, ERP introduces exposure much earlier on in treatment than standard CBT protocols

Whiteside et al., 2015

feasibility dismantling study comparing the AMS component of standard CBT with a parent-coached exposure therapy. The intervention emphasising early exposure was both more effective and more efficient than AMS.

Bilek et al., 2022

The finding that relaxation is not required for successful adherence to exposure has since been validated in a larger sample comparing an exposure-focused CBT protocol that omits relaxation, with a relaxation training program, with the CBT condition proving just as effective as standard CBT protocols, but requiring fewer sessions

Waters et al., 2017

evidence that adolescents showed greater impairment during extinction learning compared to adults and children

Clark & Wells, 1995

Cognitive model of SAD

Salkovskis, 1991

Safety behaviours can inadvertently maintain anxiety symptoms by not allowing the individual to learn that the feared outcome is, in fact, manageable

Evans, Chiu, et al., 2021

safety behaviours in adolescents with SAD fit into the same two-factor structure found in adults: avoidant and impression management behaviours. both types of safety behaviours are associated with social anxiety symptoms in community and clinical samples, although the frequency of impression management increases with age

Kilford et al., 2016

Adolescence is a period when the meta-cognitive processes required for self-consciousness are developing, suggesting this may be a time of heightened vulnerability to overreliance on SFA

Leigh & Clark, 2018

Evaluating Clark and Wells model for adolescents. some correlational evidence to suggest that SFA is higher in more socially anxious adolescents and adolescents with SAD compared to those without

Leigh, Chiu, et al., 2021

experimental study manipulating SFA and safety behaviours. non-clinical sample of 11–14-year-olds with high or low levels of social anxiety.

Before one conversation with a stranger, participants were instructed to focus on themselves and use safety behaviours

In the other conversation, they were instructed to do the opposite.

Use of SFA and safety behaviours led to an increase in both self- and observer-rated anxiety in both groups.

Chiu et al., 2022

• Negative self-images in adolescents tend to relate to fears of displaying anxiety and fears around judgement

• observer-perspective mental images predicted more social anxiety symptoms 4-6 months later

Leigh et al., 2020

experiment looking at manipulating negative self-imagery

when asked to hold a negative instead of a neutral self-image in mind during a conversation, participants report feeling more anxious, and are judged as appearing more anxious by conversation partners.

When using negative self-imagery in this study, participants also spontaneously used more safety behaviours

Evans et al., 2021

SAD appears to be one of the main predictors of poor CBT outcomes

Chiu et al., 2021

Safety behaviours, SFA, and negative self-imagery all independently associated with social anxiety over time

Leigh et al., 2023

Negative cognitions, attitudes, and safety behaviours were higher in the clinical SAD group vs. non-SAD AD control and non-clinical control groups.

SFA was higher in clinical SAD vs. anxiety control group, but not when compared to community control

Creswell et al., 2021

In some CT treatment protocols, individuals are encouraged to carry out the SFA conversation experiment used by Leigh et al. (2021) to discover for themselves the unhelpful effects of this process. Negative self-images are targeted by looking at videos of the individual from the experiment and trying to focus on the situation in its entirety to notice that focusing on perceived flaws can provide a very biased, unrealistic self-view.

Leigh et al., 2021

preliminary evidence to support the efficacy of CT for adolescents, with 75% of a feasibility sample showing good improvements in SAD symptoms

Ingul et al., 2013

CT for SAD showing superior outcomes to group CBT and an attention control in adolescents

Schwarz & Stangier, 2023

may be scope for developing interventions to prevent processes that can contribute to the worsening of social anxiety symptoms before they fully develop, such as supporting mental imagery control

Pickard et al., 2020

many of the correlates of SAD appear to be common to both neurotypical and autistic adolescents

Hollocks et al., 2023

rates of SAD elevated in autistic young people compared to the general adolescent population

Wilson & Gullon-Scott, 2023

evidence in adults suggesting that additional factors maintain the disorder for autistic individuals, such as distress around uncertainty

Bruce et al., 2005

SAD persists in the absence of treatment

Clark, 1986

cognitive theory of panic

Clark, 1996

CT for PD (adults)

Clark et al., 1994

12 sessions of CT compared to applied relaxation control, imipramine, or a waitlist in adults

CT significantly more effective at reducing PD severity than any other condition and these benefits were also maintained over time

Clark et al., 1999

Efficacy of CT has also been demonstrated in a brief format, reducing therapist time and allowing more people to access treatment (adults)

Pincus et al., 2010

Large effect sizes have been found for a modified 11-weekly-session version of PCT for adolescents (PCT-A) (only 26 ppts tho?)

Gallo et al., 2014

large effect sizes also found for 8-day intensive version of PCT-A

Baker et al., 2022

Qualitative analysis of the experiences of adolescents with PD

highlighted the impact of the school environment and peer interactions on maintaining their disorder and elevating distress.

2 superordinate themes identified: drowning in sensations; an unacceptable self

Baker & Waite, 2020

Clinicians struggle to identify panic disorder or identify appropriate treatments

Hewitt et al., 2021

Semi-structured interview.

Mental images enhanced the intensity of panic.

Six superordinate themes, including being unable to think and fearing losing control of one’s mind, feeling completely out of control during the attack, feeling embarrassment and shame, feeling cut off and isolated from others

Reardon et al., 2020

Only around 3% of young people meeting diagnostic criteria for an anxiety disorder access CBT.

The most common facilitators to help-seeking for both parents and young people are past positive experiences with mental health services and encouragement from support networks

Reardon et al., 2017

multiple stages at which parents and young people seeking help encounter barriers: initial recognition of anxiety, the decision to access support, and actually receiving support.

Many parents report uncertainty about whether their child’s anxiety is normal, where to go for support, and what help is available

Radez et al., 2022

young people report concerns such as preferring self-reliance, not viewing their problem as ‘bad enough’, worries about therapist confidentiality and trustworthiness, fear of parental reactions, and previous negative experiences of mental health services.

Haavik et al., 2017

Adolescent males are less likely to seek support for mental health difficulties than their female peers, particularly due to social norms around masculinity and seeming ‘weak’ for getting help, and less mental health knowledge

Sit et al., 2022

Many young people have expressed negative perceptions of mental health services through social media, sharing negative experiences on sites such as Reddit and TikTok

Anderson et al., 2019

Reviewed of school-based identification programmes:

• found 27 studies which fit the inclusion criteria

• only 1 was a RCT

• many of the studies were of low quality, and only two reported referral data

• some evidence to suggest that student-report universal screening is twice as sensitive as teacher nomination.

Reardon et al., 2022

More recently, the ‘Identifying Child Anxiety through Schools’ (iCATS) programme has been developed and compared with usual school practice in an RCT in UK primary schools

Creswell et al., 2017

When compared to a common brief treatment frequently used in NHS settings, solution-focused brief therapy (SFBT), GPD-CBT was found to have similarly beneficial outcomes but was much more cost-effective

Cobham et al., 2024

In a pilot study, benefits have even been found from workshops for parents delivered in a single day, providing a potential option for parents unable to commit the time to weekly sessions, although this needs to be explored on a larger scale

Creswell et al., 2024

Online Support and Intervention (OSI) for child anxiety has recently been developed and was co-designed with parents to reflect what they need from an intervention. When compared with treatment as usual in clinical practice (mostly CBT), OSI with therapist support required nearly 50% less therapist time while showing comparable results.

Waite et al., 2019

However, when compared to a waitlist in routine clinical practice, there does not appear to be a benefit of internet-delivered CBT

Clark, 2011

IAPT in the UK

Rapee et al., 2017

Trialling a stepped-care approach in a sample of children and adolescents with anxiety disorders, compared a 3-stepped model to a 10-session standard CBT protocol.

Both treatment approaches yielded similar benefits, but the stepped model required much less therapist time.

Vasa et al., 2020

Therapy designed for anxiety in neurotypical children can often be unhelpful for autistic children, encouraging masking behaviours and pathologising anxieties arising from the difficulty of navigating a world designed for neurotypicals

Cullingham et al., 2023

A trial is currently in progress examining the efficacy of a co-developed modified version of OSI for autistic children

Guzick et al., 2023

Another study piloting a form of internet-delivered CBT for autistic young people has shown promising results

Jystad et al., 2024

Socially anxious adolescents less likely to complete high school

Zeytinoglu et al., 2021

Maternal shyness at age 4 was positively associated with adolescent social anxiety but not generalised anxiety at age 15

Social Anxiety Disorder (DSM 5)

significant and persistent fear of being humiliated or judged by others, and thus of the social situations in which this may arise, which causes impairment and disproportionate distress

Panic Disorder (DSM 5)

an anxiety disorder characterised by recurrent panic attacks, which are often seemingly unprovoked, and a fear of future panic attacks. Panic attacks are sudden surges of intense fear accompanied by at least four different physiological or cognitive symptoms which, for individuals with PD, may be catastrophically misinterpreted, and they will often go to extreme measures to reduce the chance of having a further panic attack, such as engaging in safety behaviours or avoiding situations where a panic attack has previously occurred.

Wells, 1995

cognitive model of GAD

Halldorsson & Creswell, 2017

3 potential maintenance factors for child SAD: parental factors, peer factors, and performance factors

Wood et al., 2022

autistic young people had similar perceptions of their own social performance compared to observers overall. Participants who experienced greater social anxiety also received poorer subjective and objective ratings on their social performance

only interoceptive sensibility or awareness of bodily sensations fully mediated the relationship between subjective social performance rating and social anxiety.

Solmi et al., 2022

Nearly all mental health disorders have their first onset in adolescence

Plaisted et al., 2022

Affect labelling vs coping statements public speaking exposure experiment.

Foulkes & Andrews, 2023

Prevalence inflation hypothesis:

awareness efforts contributing to reported increase, via improved recognition and overinterpretation