Anxiety Disorders in Childhood

What is Anxiety

• Anxiety = mood state characterized by strong negative emotion and bodily symptoms of tension in which the child apprehensively anticipates future danger or misfortune

Anxiety vs. Fear

Fear: Emphasis on present danger

• Yvonne, age 7, is camping for the first time. Sleeping in her tent at night, she hears rustling in the woods. She thins it might be a bear. Yvonne starts breathing hard and she can feel her heart beating fast

Anxiety: Emphasis on future or possible danger

• Yvonne, age 9, is refusing to go to Girl Scout sleep away camp this summer because last time she went camping, she swears she heard a bear right outside her tent

Stress is not “bad”

• Yerkes-Dodson Law: Performance improves with physiological and mental arousal, but only up to a point

• Adaptive in that it prepares us to encounter and manage threats/challenges

• Moderate anxiety is okay, even helpful

Developmentally Typically Fears and Anxieties

Early childhood (0-5)

• Separation from parents

• Physical injury

• Thunder, lightening

• Animals

• Death, dead people

Middle childhood (5-11)

• Monsters, ghosts

• Serious illness

• Natural disasters

• School anxiety

• Safety

Adolescence (11-18)

• Social relations

• Rejection from peers

• Personal appearance

• Future

• Safety

DSM-5 Anxiety Disorders

Unfounded anxiety produces clinically significant distress or life impairment

• 309.21 Separation anxiety disorder

• 312.23 Selective mutism

• 300.29 Specific phobia

• 300.23 Social anxiety disorder

• 300.01 Panic disorder

• 300.22 Agoraphobia

• 300.02 Generalized anxiety disorder

• 293.84 Anxiety disorder due to another medical condition

• 300.09 Other specified anxiety disorder

• 300.00 Unspecified anxiety disorder

• (300.7 Illness anxiety disorder)

When is anxiety a disorder?

• Distress and/or impairment

• Duration - usually longer than 6 months or so

• Overestimation of danger; fear is simnifically out of proportion to the situation

• Persisting beyond developmentally normative period

• Not better explained by physiological effects of a medical condition or substance

• Not better explained by another mental disorder

Prevalence of Anxiety Disorder

Childhood (overall 12.3%)

• Specific Phobia (6.7%)

• Separation Anxiety (3.9%)

• Social Phobia (2.2%)

• GAD (1.7%)

Adolescence (overall 11.0%)

• Specific Phobia (6.6%)

• Social Phobia (5.0%)

• Separation Anxiety (2.3%)

• GAD (1.9%)

• Panic Disorder (1.1%)

What does anxiety look like in children and teens?

• Excessive worry

• Clinginess

• Frequently seeking reassurance

• Checking and double-checking

• Tension

• Avoidance

• Difficulty sleeping

• Irritability and anger

• Negativity

• Defiance

• Difficulty focusing

Etiology of Anxiety: Anxiety

Biopsychosocial Model

• Biological

• Social/Cultural

• Psychological

Genetics

Genotype increases risk for anxiety disorders

• Moderate heritability

Affect the way the brain and body respond to stress

Sympathetic Nervous System

• Cardiovascular - HR increase

• Respiratory - Rate of breathing increases

• Sweat glands - Cools the body

• Other effects - Pupils dilate, digestion slows

• Anxiety disorders - excessive SNS baseline activity and reactivity to stressors (heart rate, skin conductance)

• Individual differences in sensitivity to and interpretation of physiological cues

Neurobiology of Anxiety Disorders

Overactive fear circuitry in the brain

• Threat → amygdala → HPA axis

  • Overactive amygdala

The Two Fear Pathways

1. “Long route”: thalamocortico-amygdala pathway

2. “Short route”: thalamo-amygdala pathway

Hypothalamic-Pituitary-Adrenal (HPA) Axis

Threat → amygdala → HPA axis

HPA axis: neuroendocrine adaptation component of the stress response

Cortisol mobilizes glucose stored in liver to give the body a supply of energy to deal with the stressor

HPA axis dysregulation seen in anxiety disorder

Behavioral Inhibition System (BIS)

• BIS activated when threat is perceived

• Overactive BIS: excessive fear, hypersrousal, negative emotionality

• Anxiety disorders associated with overactive fear circuitry in the brain

Interplay between genes and environment

Behaviorally inhibited temperament

• Sensitive, supportive parenting → Build sense of confidence, belief that anxiety can be tolerated and managed

• Harsh, critical parenting → Emotion dysregulation, avoidance

Social Dimension

• Stress exposure

  • Daily stressors

  • Unsafe environments, material deprivation

  • Traumatic events

  • Stressful relationships

• Lack of social support

Gender Differences

• Women ~2x more likely to experience anxiety disorders

• Anxiety more prevalent in girls than boys

  • Brain chemistry and hormones may play a role

  • Gender-based socialization of emotional expression

  • Higher exposure to certain adversities

  • Greater ruminative (going over something over and over again) tendencies in girls

• Gender-based socialization of emotional expression

Psychological Dimensions

• Interpretive bias

• Attentional biases

• Cognitive inflexibility

• Locus of control

• Attachment atyles

Maladaptive Beliefs

• Probability overestimation

• Low coping self-efficacy

• Cost overestimation

• Maladaptive beliefs about experiencing anxiety

• Intolerance of uncertainty

• Maladaptive mindsets toward thoughts and feelings

Selective Attention

• Focusing attention toward threatening stimuli in the context of both neutral and nonthreatening stimuli

• Clients may benefit from attention bias modification training

Interpretive Bias

• Predisposition toward negative or erroneous interpretations of neutral, ambiguous, or potentially threatening stimuli

• Examples: personalization, selective abstraction, overgeneralizatoin

Behavioral Learning

• Classical conditioning (aka respondent learning)

• Vicarious learning (social modeling)

• Operant conditioning

Separation Anxiety Disorder

• Excess and developmentally inappropriate anxiety involving separation from people with whom the child is attached

SAD Symptoms: Examples

• Extreme distress when anticipating or experiencing separation from caregiver

• Persistent and excessive worry about something bad happening that could cause separation from caregiver (e.g., kfidnappigng)

• Repeated nightmares involving the theme of separation

• At least 3 symptoms for 4+ weeks

SAD Prevalence and Course

• One of the two most common anxiety disorders in childhood

  • 4-10% of children

  • Girls > boys

• Onset in middle childhood, often after stressful event

• Heterotypic continuity: what happens with the disorder overtime varies

  • About half go on to develop depression

  • About a third of cases can persist into adulthood

• Insidious onset: slow and gradual

Selective Mutism

• Inability to communicate effectively in certain social situations

• May be completely silent, may whisper, or talk to selective people

• Able to speak and communicate in settings where they feel relaxed

• Very shy, inhibited

Selective Mutism

• Rare - occurs in 0.7% of children

• Average onset about 3 - 4 years old

• Often significant lag between onset and referral

• Many children “outgrow” the disorder

• 45%-75% later meet criteria for SOC

Specific Phobia

Fears that…

• Are developmentally inappropriate

• Persist

• Are irrational or exaggerated

• Lead to avoidance

• Cause impairment in normal routines (not diagnosable if isn’t present)

• Lifetime prevalence 12.5%-20%

• Girls > boys

• Onset in middle to late childhood

Specific Phobia Subtypes

1. Blood-injury-injection

2. Situational

3. Natural environmental

4. Animal

5. Other

Normal fears vs. Phobia

Normal Fear

• Feeling anxious when flying through turbulence or taking off duringa. storm

• Experiencing butterflies when peering down from the top of a skyscrapper

• Getting nervous when you see a pit bull or rottweiler

Phobias

• Not going to your best friend’s island wedding because you’d have to fly there

• Turning down a great job because it’s on the 10th floor of the office building

• Steering clear of the park because you might see a dog

Generalized Anxiety Disorder (GAD)

• Excessive, uncontrollable worry about a variety of situations

• Often perfectionistic, approval-seeking

• Imagining worst possible outcome, “what if” thinking

• Underestimate their own ability to cope

GAD

• Associated features: Tension, restlessness, difficulty sleeping, fatigue, somatic symptoms, difficulty concentrating

• Onset usually in early adolescence

• Prevalence low in community population, high in treatment-seeking population

Social Anxiety Disorder (aka Social Phobia)

• Anxious about social situations, performance

• Feared outcome is humiliation, embarrassment, or rejection

• For children, anxiety must be observed with peers and adults

• Avoid meeting new people, difficulty engaging in social situations

• May be self-critical and highly emotional

Social Anxiety Disorder

• Lifetime prevalence: 6-12%

• Onset typically after puberty

• Affects twice as many girls as boys

• Often reluctant to seek treatment

• Low rates of spontaneous remissoin