PSCL 344 Exam 3

Adolescent Substance-Use Disorders (Overview)

• Substance use during adolescence exists on a continuum from experimentation to disorder.

• Adolescents are especially vulnerable due to brain development, peer influence, and risk-taking tendencies.

• Early use increases the likelihood of later Substance Use Disorders (SUDs).

DSM-5 Criteria Groupings

Impaired Control

• Loss of control over amount, frequency, or duration of use.

• Strong cravings and unsuccessful attempts to stop.

Social Impairment

• Substance use interferes with school, family, or peer relationships.

• Important activities are reduced or abandoned.

Risky Use

• Continued use despite physical, psychological, or safety risks.

• Use in dangerous situations (e.g., driving).

Pharmacological Criteria

• Tolerance: needing more substance for same effect.

• Withdrawal: physical or psychological symptoms when stopping.
  

What is substance use disorder?

• A problematic pattern of use causing significant distress or impairment.

• Requires at least 2 symptoms within 12 months.

• Severity increases as more criteria are met.
  

What are the key DSM-5 Criteria?

1. Using more than intended

   • Loss of control over consumption.

2. Unsuccessful efforts to cut down

   • Desire to stop but inability to do so.

3. Time spent using or recovering

   • Substance use becomes central to daily life.

4. Craving

   • Intense urges that drive continued use.

5. Failure to meet obligations

   • Academic decline, skipped school, family conflict.

6. Continued use despite problems

   1. Social/interpersonal harm doesn’t stop use.

7–8. Reduced activities

• Substance use replaces normal teen activities.

9–10. Risky use

• Physical danger or worsening health ignored.

11–12. Tolerance & withdrawal

• Signs of physiological adaptation.

Remission and severity specifiers

• Early remission: 3–12 months without criteria (except craving).

• Sustained remission: 12+ months without criteria.

• Specify if in a Controlled environment: access to substances is restricted.

• Severity levels:

  • Mild: 2–3 symptoms

  • Moderate: 4–5 symptoms

  • Severe: 6+ symptoms

Criticisms of DSM-5 for Adolescents

• Not fully developmentally sensitive.
  
  

• Normative teen behaviors (risk-taking, experimentation) may be pathologized.
  
  

• Some criteria (tolerance, risky use) are more common in teens.

Adolescent vs Adult substance use

• Adolescents: episodic bingeing, polysubstance use.

• Adults: more regular, patterned use.

• Adolescents are more influenced by peers than dependence.

Assessment for Adolescent SUD: CAGE Questionnaire

1.The CAGE questionnaire
− Four questions
C: Have you felt you should cut down on your drinking?
A: Have people Annoyed you by criticizing your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

PURPOSE

• Screens for alcohol problems.

• Quick, adult-oriented tool.

• Less sensitive to adolescent patterns.
  

Scoring

• 0 = low risk

• 1 = possible concern

• 2+ = likely problem

• 3–4 = high likelihood of dependence
  
  

Assessment for Adolescent SUD: CRAFT Questionnaire

The CRAFFT questionnaire: problematic pattern of use in 12 months
C: Have you ever ridden in a Car driven by someone (including yourself) who was high or had
been using alcohol or drugs?
R: Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
A: Do you ever use alcohol or drugs while you are Alone?
F: Do you ever Forget things you did while using alcohol or drugs?
F: Do your Family or friends ever tell you that you should cut down on your drinking or drug use?
T: Have you ever gotten into Trouble while you were using alcohol or drugs?

PURPOSE

• Designed specifically for adolescents.

• Assesses risk behaviors, context, and consequences.

• Better developmental fit than CAGE.
  
  

Scoring

• 0 = low risk

• 1 = moderate risk (monitor)

• 2+ = high risk (refer for treatment)

Prevalence and trends of substance abuse amongst adolescents

• Alcohol is the most commonly used substance.

• Cigarette use declining.

• Marijuana use increasing.

• Other illicit drugs declining or stable.

• In 2020, 6.3% of adolescents met criteria for SUD.
  

Substance abuse and age of onset

• Some experimentation is normative

• Earlier onset = higher risk for SUD.

• Alcohol use before age 14 strongly predicts later dependence.

• Early use alters brain development.
  

Sex and Ethnicity influences on substance abuse

• Gender gap is narrowing.

• Girls’ rates increasing.

• Whites and Hispanics initiate alcohol use more than Black and Asian youth.

• Socioeconomic factors often explain differences better than race.

Course of Adolescent substance use

• Peaks in late adolescence.

• Declines in young adulthood.

• Strong links to:

  • unsafe sex

  • delinquency (smoking, drinking and driving)

  • dating violence

Overdose deaths rising due to fentanyl contamination.

Associated Characteritics of SUD

• Polysubstance use

• Academic failure

• Delinquency

• Parental conflict

• Disrupted neurodevelopment

• Impaired executive functioning and impulse control
  

Causes of Adolescent SUD

Biological/Developmental

• Sensation seeking

• Circadian rhythm shifts

• Immature prefrontal cortex

Family

• Low monitoring

• Poor attachment

Peers & Culture

• Deviant peer groups

• Normalization (“everyone’s doing it”)

Developmental Pathways to SUD

Enhanced Reinforcement Pathway

• Genetic sensitivity to reward.

• Substances feel especially reinforcing.
  
  

Negative Affect Pathway

• Substance use as coping for stress, anxiety, or depression.
  

Deviance-Prone Pathway

• Behavioral undercontrol.

• Early conduct problems.

• Academic failure and deviant peers.
  

Evidence Based Prevention

• Primary prevention: DARE increases knowledge but not behavior change.

• Secondary prevention: ecological approaches targeting family, school, peers.

Medication Treatments for SAD

Medication
− Substitution therapy to eliminate cravings
 Methadone, nicotine replacement
− Detoxification to help patients cope with withdrawal
 Clonidine
 Acamprosate
− Block the effects of alcohol and other drugs
 Naltrexone: opioid receptor antagonist
 Bupropion: atypical antidepressant, affects dopamine, and norepinephrine
− Aversion therapy
 Disulfiram (antabuse): prohibits alcohol metabolism
− Medication for dual diagnosis
 Stimulants

Psychosocial Treatments for SAD

Psychosocial treatments
1. Inpatient treatment: 12 step program
28-day inpatient treatment programs
SUD is a disease
− Treatment goals
1. to attend to the adolescent’s immediate medical needs and to detoxify her body
2. to help the adolescent recognize the harmful effects of the substance on her health and
functioning
3. to improve the quality of the adolescent’s relationships with others
− Alcoholics anonymous (AA)
− Narcotics anonymous (NA)

2. CBT
Learning principles
 Operant conditioning
 Classical conditioning
 Social learning
 Beliefs
• Self monitoring
• Cost-benefit analysis
• Social skills training (relaxation, assertive, and problem-solving)
• Examining beliefs

Motivational Interviewing

Motivational enhancement therapy/motivational interviewing
− Goal: increase motivation and harm reduction
− Stages: Precontemplation, contemplation, and action maintenance (avoiding
relapse)
− Five principles: express empathy, develop discrepancies, avoid argumentation,
support commitment, and promote self-efficacy
− MI Skills: open-ended questions, affirmations, reflections, summaries

Family Therapy for SUD

Family therapy (multidimensional family therapy)
Cause = family + social system
− Goals
 help parents manage their adolescent’s substance use
 improve the quality of family functioning
− Four dimensions
 adolescent’s SU
 parenting practices
 relationship quality and communication strategies
 social factors, peer relationships, and school

A P-DD Diagnosis requires:

• Depressed or irritable mood for at least one year
• At least two additional symptoms, such as:
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

An MDD Diagnosis Requires

• At least 5 symptoms present during the same 2-week
period, representing a change from previous functioning.
• One of the symptoms must be either:
• Depressed mood (can present as irritability in youth), or
Loss of interest or pleasure (anhedonia)
• Other possible symptoms include:
• Significant weight loss or gain, or change in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicidal ideation

How does depression look across development

Depression Across Development

Depression looks different at different ages, which contributes to underdiagnosis:

• Infants may show withdrawal and failure to thrive when emotionally deprived (anaclitic depression).

• Preschoolers often appear somber, tearful, clingy, or joyless.

  • diffuse symptoms

• School-age children show irritability, tantrums, and disruptive behavior alongside sadness.

  • DMDD often emerges

• Adolescents more closely resemble adults, showing low self-esteem, hopelessness, social withdrawal, and self-blame.

  • MDD and P-DD differentiate
    
    

Understanding these developmental differences is critical for accurate identification.

DMDD vs ODD

key differences between Disruptive Mood Dysregulation Disorder (DMDD) and Oppositional Defiant Disorder (ODD)

• DMDD is defined by a chronic negative mood (irritability) with frequent temper outbursts, whereas ODD centers on defiant and argumentative behavior without a persistent mood disturbance. DMDD requires symptoms to be present for at least 12 months, start before age 10, occur across multiple settings, and include impairment, whereas ODD has fewer mood-based requirements and more flexibility in context.

Psychodynamic Theories of depression

• From a psychodynamic perspective, depression is seen as anger turned inward, often following the loss (real or symbolic) of an important relationship.

• Early theorists believed children lacked a fully developed conscience (superego), so depression was thought not to occur in youth;

• however, later views emphasize that excessive guilt and shame (which require a conscience) play a major role in depressive symptoms in children and adolescents.

Attachment and Depression

Attachment theory emphasizes that early disruptions in caregiving relationships increase vulnerability to depression. When caregivers consistently fail to meet a child’s needs, the child may develop insecure attachment, leading to negative beliefs about themselves (“I am unlovable”) and others as threatening or undependable (“People are unreliable”), which increases long-term risk for depression.

Behavioral and Cognitive Theories of Depression

• Behavioral: emphasize the importance of learning and environmental
consequences
− Depression is related to a lack of response-contingent positive reinforcement
• Cognitive: focus on relationship between negative thinking (rumination) and
mood
− Emphasize depressogenic cognitions
− Hopelessness theory
 Information-processing biases, or errors in their thinking in specific situations, called
negative automatic thoughts
 Negative view about oneself, the world, and the future (negative cognitive triad)

What is the negative cognitive triad

This concept explains depression as involving three interconnected negative beliefs: about the self, the world, and the future. These beliefs reinforce one another and contribute to feelings of hopelessness and helplessness.

What are depressogenic cognitions?

• Depressogenic cognitions refer to systematic thinking errors that bias how children interpret experiences

• Selective attentional bias

• Negative automatic thoughts
  − All or none (extremes)
  − Overgeneralization (broad conclusions from single event)
  − Disqualifying positives (rejecting complements)
  − Jumping to conclusions (assumptions w/o evidence; mind reading; fortune telling
  − Magnification and minimization (exaggerate failures minimize strengthens)
  − Emotional reasoning (feelings reflect fact)
  − Should statements (ridged rules about how things should be)
  − Labeling and mislabeling (global labels based on behavior)
  − Personalization (blaming self for things out side of control)

other theories of depression

Self-control theories: youths with depression as having deficits in self-
monitoring, self-evaluation, and self-reinforcement
• Interpersonal models: disruptions in interpersonal relationships
• Socioenvironmental models: emphasize the relationship between
stressful life events and depression
− Diathesis-stress model
• Neurobiological models: focus on genetic vulnerabilities and
neurobiological processes
− Effects of stress, child maltreatment, or maternal depression

Types of Mood Disorders

• The spectrum runs from severe depression to extreme mania
• DSM-5-TR divides mood disorders into two general categories:
− Depressive disorders: excessive unhappiness (dysphoria) and loss of
interest in activities (anhedonia)
− Bipolar disorder: mood swings from deep sadness to high elation (euphoria)
and expansive mood (mania)

What is depression?

Depression is not just feeling sad—it is a pervasive unhappy mood disorder that affects emotions, thinking, physical functioning, and behavior. Depressed youth struggle to “snap out of it,” and their symptoms are persistent and impairing. Depression frequently co-occurs with anxiety, conduct problems, and ADHD, which can cause the depressive symptoms to be overlooked because other behaviors draw more attention.

History of depression in children

• In the past
− Mistakenly believed that depression did not exist in children in a form
comparable to that in adults
− Symptoms of depression—typical and passing expressions of certain stages
of development
• We now know
− Children do experience recurrent depression
− Depression in children is not masked, but rather may be overlooked
− It frequently co-occurs with other more visible disorders

Depression in young people

• Almost all young people experience some symptoms of depression
− Many experience significant depression at some time
− Is displayed as a lasting depressed mood with disturbances in
 Thinking
 Physical functioning
 Social behavior
• Suicide among teens is a serious concern
• 90% of youth with depression show impairment in daily functions

Depression and Development

• Experience and expression of depression change with age
• In children under the age of 7
− Tends to be diffuse and less easily identified
− Anaclitic depression—infants:
 Infants raised in clean but emotionally cold institutional environment show
depression-like reactions, sometimes resulting in death
 Similar symptoms can occur in infants raised in severely disturbed families

• Preschoolers: may appear extremely somber and tearful
− Lacking exuberance; may display excessive clinging and whiny
• School-age children: many of the symptoms of preschoolers
− Plus, increasing irritability, disruptive behavior, and tantrums
• Preadolescents and adolescents: similar symptoms of younger children
− Plus, self-blame, low self-esteem, persistent sadness, and social inhibition

Anatomy of depression

Depression can be understood as:

• a symptom: feeling sad or miserable

• Syndrome: group of symptoms that occur together

• Disorder: comes in several forms

  • Major Depressive Disorder (MDD)

  • Persistent Depressive Disorder (PDD) or dysthymia

  • Disruptive mood dysregulation disorder (DMDD)

Major Depressive Disorder

Diagnosis in children
− Same criteria for school-age children and adolescents
− Depression is easily overlooked because other behaviors attract more
attention
− Some features (e.g., irritable mood) are more common in children and
adolescents than in adults
− Diagnosis of MDD depends on the presence of a major depressive episode plus the exclusion of other conditions

Young People with MDD

• Display similar symptoms and have comparable rates of comorbidity and
recurrence as adults
• However, as compared with adults
− Clinic-referred youths with MDD have almost exclusively
− First-episode depressions
− Will recover somewhat faster from their depressive episodes
− Are at greater risk for developing bipolar disorder

Prevalence of MDD

• Between 2% and 8% of children aged 4 to 18 experience MDD
• Depression is rare among preschool and school-age children (1%–3%)
− Increases two- to threefold by adolescence
• Adolescent depression increased 59% between 2007 and 2017
− This trend continued throughout the coronavirus pandemic

MDD Comorbid disorders

• As many as 90% of young people with depression have one or more
other disorders; 50% have two or more
• Most common comorbid disorders include
− Anxiety disorders (especially GAD), specific phobias, and separation anxiety
disorders
• Other common comorbid disorders are
− Persistent depressive disorder (P-DD), conduct problems, ADHD, and
substance-use disorder

Onset, course, and outcome of MDD

• Onset may be gradual or sudden
• Usually, a history of milder episodes that do not meet diagnostic criteria
• Age of onset usually between 13 and 15 years—average episode lasts
eight months
• Most children eventually recover from initial episode
− Chance of recurrence is 25% within one year, 40% within two years, and
70% within five years
− About one-third develop bipolar disorder within five years after onset of
depression (bipolar switch)

Gender and MDD

• The ratio of girls to boys is about 2:1 to 3:1 after puberty
• Differences in emotional reactivity are present as early as the preschool period
− Boys displaying more anger
− Girls more sadness
• Higher rates of depression in youth reporting their sex as female and
identifying as nonbinary or male, transman, or transmasculine
• Gender Intensification Hypothesis: difference is due to the increased societal
pressure for girls and boys to conform to normative gender roles during
adolescence

Ethnicity and Culture and MDD

• Incidence of depression varies across regions worldwide
• Non-White (African American, Hispanic, and Asian) adolescents reported more
symptoms of depression than White adolescents
• These differences may reflect the impact of structural factors such as
− Differences in socioeconomic status (SES)
− Marginalization
− Structural racism
• Low SES may increase vulnerability to stress, and may increase the likelihood
of depression

Persistent Depressive Disorder

P-DD is characterized by chronic, low-grade depression lasting at least one year in youth.

• Is characterized by symptoms of depressed mood that occur on most
days, and persist for at least one year
• Child with P-DD also displays at least two somatic or cognitive symptoms
• Symptoms are less severe, but more chronic than those of MDD
• Poor emotion regulation
• Children with both MDD and P-DD (double depression)
− More severely impaired than children with just one disorder

Prevalence and comorbidity of PDD

• Approximately 1% of children and 5% of adolescents display P-DD
• The most prevalent co-occurring diagnosis with P-DD is MDD
• About half of the children with P-DD
− Have one or more co-occurring non-affective disorders that preceded the P-
DD, including
 Anxiety disorders
 Conduct disorder
 ADHD

Onset, course, and outcomes of PDD

• P-DD develops most commonly around 11 to 12 years of age
• Childhood-onset P-DD has a prolonged duration
− Average episode length of two to five years
• Almost all children eventually recover from P-DD
• Have a high risk of developing other disorders
• Long lasting episodes of P-DD can have extremely harmful effects on
development
• Early-onset P-DD is almost always followed by MDD and sometimes by
BP

Disruptive Mood Dysregulation Disorder (DMDD)

• The central feature of disruptive mood dysregulation disorder (DMDD) is
chronic, severe persistent irritability
• Two main clinical features
− Frequent verbal or physical temper outbursts
− Chronic, persistently irritable or angry mood
• Occurs predominantly in males and in school age children
• Has high comorbidity with anxiety, mood, and disruptive behavior
disorders
• Markedly disrupts the youth’s family

Intellectual and Academic Functioning in Depression

• Difficulty concentrating, loss of interest, and slowness of thought
− May have a harmful effect on intellectual and academic functioning
 Lower scores on tests, poor teacher ratings, and lower levels of grade
attainment
• Interference with academic performance
− Not necessarily related to intellectual deficits
− May have problems on tasks requiring attention, coordination, and speed
• Difficult to determine whether depression is a cause or an outcome of
learning difficulties

Cognitive Biases and Distoritions

• Selective attentional biases
• Feelings of worthlessness, negative beliefs, attributions of failure, self-
critical and automatic thoughts
• Depressive ruminative style, pessimistic outlook, and negative self-
esteem
• Negative thinking and faulty conclusions generalized across situations,
hopelessness, and suicidal ideation

Negative Self-Esteem in Depression

• Low self-esteem is the symptom that seems most specifically related to
depression in adolescents
• Daily fluctuations in self-esteem appear to be related to depression
following exposure to major life stresses
• Self-esteem problems in adolescent girls are often related to a negative
body image
• Children whose self-views are negative and narrowly focused in one
domain
− May show instability in their self-esteem because they lack alternative
compensatory areas of functioning

Social, Peer, and Family Problems and Depression

Social and peer problems
− Few close friendships, feelings of loneliness, and isolation
− Social withdrawal and ineffective styles of coping in social situations
 Co-rumination: negative form of self-disclosure and discussion between peers focused
narrowly on problems or emotions to the exclusion of other activities or dialogue
• Family problems and a child with depression
− Has less supportive and more conflicted relationships with parents and siblings
− Feels socially isolated from families and prefers to be alone

Depression and Suicide

Most youngsters with depression think about suicide, and as many as
one-third who think about it, attempt it
• Drug overdose and wrist cutting are among the most common methods for
adolescents who attempt suicide
• Most common methods for those who complete suicide are firearms,
suffocation, and poisoning
• Worldwide, the strongest risk factors are having a mood disorder and
being a young female
• Ages 13 and 14 are the peak periods for a first suicide attempt by those
with depression

Causes of Depression

Developmental Framework:

• Due to the many interacting influences, multiple pathways to depression are likely
  − Genetic risk influences neurobiological process and is reflected in early temperament characterized by:
   Oversensitivity to negative stimuli
   High negative emotionality
   Disposition to feeling negative affect
  − These early dispositions are shaped by negative experiences in the family

• genetic and family risk

  • • Twin and other genetic studies suggest moderate genetic influence, with heritability estimates ranging from 30% to 45%
    • Children of parents with depression have about three times risk of having depression
    • What is inherited is likely a vulnerability to depression and anxiety
    − With certain environmental stressors needed for these disorders to be expressed

• neurobiological influences

  • Irregularities in the structure and function of several brain regions that regulate emotional functions
    • Irregularities in amygdala, cingulate, prefrontal cortex, hippocampus
    • Cortical thinning in the right hemisphere
    • HPA axis dysregulation, sleep Irregularities, variants in BDNF, and neurotransmitters have also been implicated
    − Serotonin
    − Dopamine
    − Norepinephrine

• family influences

  • • When children are depressed
    − Families display more critical and punitive behavior toward the depressed child than toward other children
    • When parents are depressed
    − Depression interferes with the parent’s ability to meet the needs of the child
    − Child experiences higher rates of depression, phobias, panic disorder, and alcohol dependence as adolescents and adults

• Stressful life events

  • • Depression is associated with both severe and non-severe stressful life
    events
    • Triggers for depression may involve
    − Interpersonal stress and actual or perceived personal losses
    − Life changes
    − Violent family environment
    − Extreme lack of family resources
    − Daily hassles and other non-severe stressful life events

• Emotional regulation

  • Children who experience prolonged periods of emotional distress and
    sadness may
    − Have problems regulating negative emotional states
    − Be prone to depression
    − May use avoidance or negative behavior to regulate distress, rather than
    problem-focused and adaptive coping strategies

Treatments for depression

Only about half of children with depression receive help for their problem
− Rates vary by racial/ethnic background
• Cognitive–behavioral therapy (CBT): most success in treating children
and adolescents with depression
• Interpersonal Psychotherapy for Adolescent Depression (IPT-A): focuses
on improving interpersonal communication and has also been effective
• Psychopharmacological treatments: concerns raised about their
effectiveness, overuse, and possible side effects

Psychosocial interventions

• Behavior therapy
− Focuses on increasing pleasurable activities and events, and providing the
youngster with the skills necessary to obtain more reinforcement
• Cognitive therapy
− Teaches depressed youngsters to identify, challenge, and modify negative
thought processes
• Cognitive–behavioral therapy (CBT)
− Most common form of psychosocial intervention combining behavioral and
cognitive therapies

Primary and Secondary Control Enhancement Training (PASCET)
− Primary control skills (ACT skills)
− Secondary control skills
• The ACTION Program
• Adolescent Coping with Depression Program (CWD-A)
• Interpersonal Psychotherapy for Adolescent Depression (IPT-A)

Medications for depression

• About 1 million youths in the United States receive antidepressant
medication each year
• SSRIs have clearly become the first line of antidepressant medication
treatment
• Concerns have been voiced about their use with children and
adolescents
− Possible serious side effects such as suicidal thoughts
− Lack of information about the long-term effects
− Up to 60% of depressed youngsters respond to placebo

Depression prevention

• CBT and interpersonal psychotherapy are most effective at lowering the
risk for depression and for preventing recurrences
• Large-scale prevention: focus on the early detection of high school
students at risk for depression and suicide to ensure that these students
receive help
• Family cognitive–behavioral interventions
• Online and computer-based interactive programs for use in primary care,
school, and other settings are examples of promising new prevention
approaches

Bipolar Disorder

Bipolar disorder (BP)
− A striking period of unusually and persistently elevated, expansive, or
irritable mood, accompanied by increased goal-directed activity or energy
− Alternating with or accompanied by one or more major depressive episodes
− Elation and euphoria can quickly change to anger and hostility if behavior is impeded
 May be experienced simultaneously with depression

Anxiety and Depression Overlap

• Same Kids, Different Emotions...and Why the Overlap Matters
• 59-70% of kids with MDD also meet criteria for an anxiety disorder
− Anxiety almost always comes before depression
• 1 in 3 youth will meet for anxiety disorder
− Highest rate of any mental disorder in childhood
− ONLY 1 in 5 get treatment

Anxiety often precedes depression developmentally. Chronic anxiety leads to avoidance, which shrinks a child’s life (fewer activities, friendships, successes). Over time, this loss of mastery and connection increases hopelessness, setting the stage for depression. When anxiety is addressed with approach behaviors and problem-solving, mood often improves instead.

Three interrelated anxiety response systems

Anxiety involves coordinated activation across systems:

• Physical: fight/flight activation (heart rate, sweating, muscle tension).

• Cognitive: threat-focused thinking, worry, panic, difficulty concentrating.

• Behavioral: escape, avoidance, or aggression aimed at reducing fear.
  Avoidance temporarily reduces anxiety, but maintains it long-term.
  

anxiety v fear v panic

• Anxiety: future-oriented; anticipation of threat without immediate danger.

• Fear: present-oriented; response to an actual threat with strong escape urges.

• Panic: sudden surge of intense physical symptoms without clear danger.
  Understanding this distinction helps differentiate normal reactions from disorders.

Normal fears, anxieties, worries, and rituals

• Moderate fear and anxiety are adaptive
− Emotions and rituals that increase feelings of control are common in children and teens
• Normal fears
− Fears that are normal at one age can be debilitating a few years later
− A fear defined as normal depends on its effect on the child and how long it
lasts
− The number and types of fears change over time

Normal anxieties and worries

• Anxieties are common during childhood and adolescence
− Girls display more anxiety than boys, but symptoms are similar
− Some specific anxieties decrease with age
− Nervous and anxious symptoms may remain stable over time
• Children of all ages worry
− Serves a function in normal development
− Moderate worry can help children prepare for the future
− Children with anxiety disorders do not necessarily worry more
− They worry more intensely than other children

Separation Anxiety Disorder

• Separation anxiety is important for a young child’s survival
− It is normal from about age 7 months through preschool years
− Lack of separation anxiety at this age may suggest insecure attachment
• SAD is distinguished by
− Age-inappropriate, excessive, and disabling anxiety about being apart from parents or away from home
− Over time children with SAD may become increasingly withdrawn, apathetic, and depressed

Prevalence and Comorbidity of SAD

• SAD is one of the two most common childhood anxiety disorders
• Occurs in 4% to 10% of children
− It is more prevalent in girls than in boys
• More than two-thirds of children with SAD have another anxiety disorder
and about half develop a depressive disorder

Onset, course, and outcomes for SAD

• SAD has the earliest reported age of onset of anxiety disorders (7–8 years of
age) and the youngest age at referral
• Progresses from mild to severe
• Associated with major stress
• Persists into adulthood for more than one-third of affected children
• As adults, more likely to experience
− Relationship difficulties
− Other anxiety disorders and mental health problems
− Functional impairment in social and personal life

School Reluctance and Refusal in SAD

• School refusal behavior
− Refusal to attend classes or difficulty remaining in school for an entire day
• Occurs most often in ages 5 to 11
• Fear of school may be fear of leaving parents (separation anxiety), but
can occur for many other reasons
• Serious long-term consequences result if it remains untreated

Specific Phobia

• Age-inappropriate persistent, irrational, or exaggerated fear that leads to
avoidance of the feared object or event and causes impairment in normal
routine
− Lasts at least six months
− Extreme and disabling fear of objects or situations that in reality pose little or no danger or threat
− Child goes to great lengths to avoid the object/situation
• Fear or anxiety may be expressed by crying, tantrums, freezing, or
clinging

Prevalence, comorbidity, onset, course, and outcome of specific phobias

• About 20% of children are affected at some point in their lives, although
few are referred for treatment
• More common in girls
• Common co-occurring disorders another anxiety disorder and depressive
disorders
• Onset at 7 to 9 years
• Clinical phobias are more likely than normal fears to persist over time

Social Anxiety Disorder

• A marked, persistent fear of social or performance requirements that
expose the child to scrutiny and possible embarrassment
− Anxiety over mundane activities
− Most common fear is doing something in front of others
− More likely than other children to be highly emotional, socially fearful; and
inhibited, sad, and lonely
• Social anxiety disorder encompasses a variety of social fears
− Fear of performance situations
− Fear of interaction situations

prevalence, comorbidity, and course of social anxiety disorder

• Lifetime prevalence of 6% to 12% of children
• Twice as common in girls
• Two-thirds also have another anxiety disorder
• 20% also suffer from major depression and may self-medicate with
alcohol and other drugs
• Most common age of onset is early to mid-adolescence, and is rare
under age 10
• Relative to males, adolescent females may have an increasing biological
sensitivity to being evaluated by peers

Panic attacks are common (16% of teens)
• Panic disorder and agoraphobia are less common (about 2.5% of teens
13–17 years)
• Panic attacks are more common in adolescent females than adolescent
males
• Comorbidity adolescents with PD
• Most commonly have another anxiety disorder or depression
• At risk for suicidal behavior; alcohol or drug abuse

Generalized Anxiety Disorder

• Generalized anxiety disorder (GAD)
− Excessive, uncontrollable anxiety and worry
− Worrying can be episodic or almost continuous
− Worry excessively about minor everyday occurrences
• Accompanied by at least one somatic symptom, such as:
− Headaches, stomach aches, muscle tension, and trembling

Prevalence, comorbidity, onset, course, and outcome of GAD

National survey: lifetime prevalence rate is 2.2%
• Equally common in boys and girls
• Accompanied by high rates of other anxiety disorders and depression
• Average age of onset is early adolescence
• Older children have more symptoms
• Symptoms persist over time

• Lifetime prevalence in children and adolescents is 1% to 2.5%
• Clinic-based studies find it twice as common in boys
• Common comorbidities are anxiety disorders, ADHD, ODD, and vocal
and motor tics
• As the child gets older, depressive disorders, substance-use disorders,
learning disorders, and eating disorders are more common

Associated Characteristics of Anxiety

• cognitive disturbances

  • • Disturbances in how information is perceived and processed
    • Intelligence and academic achievement
    − Deficits in specific areas of cognitive functioning, such as attention, executive functions, working memory, and speech or language
    • Cognitive errors and biases
    − Perceptions of threats activate danger-confirming thoughts
    − Children with conduct problems select aggressive solutions in response to a perceived threat
    − See themselves as having less control over anxiety-related events than other children

• Physical Symptoms

  • • Somatic complaints: more common in children with GAD, PD, and SAD
    than in those with a specific phobia
    • 90% with anxiety disorders have sleep-related problems, for example,
    nocturnal panic
    • High rates of anxiety in adolescence are related to reduced accidents
    and accidental deaths in early adulthood
    • Anxiety takes its toll over time by increasing the long-term risk of serious
    health problems

• Social and Emotional Deficits

  • • Display low social performance and high social anxiety
    • See themselves as shy and socially withdrawn, and report low self-esteem, loneliness, and difficulty starting and maintaining friendships
    • Have deficits in understanding emotion and in differentiating between thoughts and feelings
    • Young children with symptoms of social anxiety may display lower levels of theory of mind

Gender, Ethnicity, and culture and Anxiety

• Gender

  • • By age 6, twice as many girls as boys have experienced symptoms of
    anxiety
    • Boys are less likely than girls to report anxiety
    • Higher incidence of anxiety disorders in girls suggests genetic influences
    and related neurobiological differences
    • Gender-role orientation in boys and girls with anxiety disorders
    − Self-reported masculinity was related to lower overall levels of fearfulness
    − No relation was found between self-reported femininity and fearfulness

• Ethnicity

  • • A higher prevalence of anxiety in underrepresented ethnic groups in the United States
    − Black American children generally report more symptoms of anxiety than do White American children
    − White American children are more likely to present with school refusal and with higher severity ratings than Black American children
    − These differences are likely impacted by structural racism and racial trauma
    • Native Hawaiian adolescents display rates of OCD that are twice as high as those of other ethnic groups

• Culture

  • • The experience of anxiety is pervasive across cultures
    • Ethnicity and culture may affect the expression, developmental course,
    and interpretation of anxiety symptoms
    • Chinese adolescents report higher levels of social anxiety than do
    American youths
    • Behavior lens principle
    − Child psychopathology reflects a mix of actual child behavior and the lens
    through which it is viewed by others in a child’s culture

Early Theories of Anxiety

• Classical psychoanalytic theory
− Anxieties and phobias seen as defenses against unconscious conflicts
rooted in the child’s early upbringing
• Behavioral and learning theories
− Fears and anxieties learned through classical conditioning and maintained
through operant conditioning (two-factor theory)
• Bowlby’s theory of attachment
− Fearfulness is biologically rooted in the emotional attachment needed for
survival
• No single theory is sufficient

Temperament and Anxiety

• Variations in behavioral reactions to novelty result in part from inherited
differences in the neurochemistry of brain structures
• 15% to 20% of children are born with a low threshold for becoming
overexcited and to withdrawing in response to novel stimulation
− Behavioral inhibition (BI): a low threshold for novel and unexpected stimuli
 Places an individual at greater risk for anxiety disorders
 Development of disorders depends on gender, exposure to early maternal
stress, and parental response

Family and Genetic Risk

• Parents of children with anxiety disorders have increased rates of current
and past anxiety disorders
• Children of parents with anxiety disorders are about five times more
likely to have anxiety disorders
• Twin studies suggest that about 30% to 40% of the variance in childhood
anxiety symptoms is accounted for by genetic influences
• There is no strong, direct link between specific genetic markers and
specific types of anxiety disorders

Neurobiological Factors and family factors involved in anxiety

• No single structure or neurotransmitter controls the entire anxiety
response system
• The entire anxiety response system is controlled by several interrelated
systems in the brain to produce anxiety
• Overactive behavioral inhibition system
• Brain irregularities have been implicated in children who are anxious
and/or behaviorally inhibited
• Primary neurotransmitter system implicated in anxiety disorders
− γ-aminobutyric acidergic (GABA-ergic) system

• Parenting practices
− Parents of anxious children are seen as overinvolved, intrusive, or limiting
child’s independence
• Prolonged exposure to high doses of family dysfunction associated with
extreme trajectories of anxious behavior
• Low SES
• Insecure early attachments

Treatment for anxiety

Main line of attack for treating anxiety disorders is exposing children to
anxiety-producing situations, objects, and occasions
• Treatments are directed at modifying
− Distorted information processing
− Physiological reactions to perceived threat
− Sense of a lack of control
− Excessive escape and avoidance behaviors

• Behavior Therapy

  • • Main technique is exposure to feared stimulus
    − While providing children with ways of coping other than escape and avoidance
    • Systematic desensitization
    • Flooding: prolonged repeated exposure
    • Response prevention prevents child from engaging in escaping or avoidance stimuli
    • Modeling and reinforced practice

• Cognitive-Behavioral therapy

  • • The most effective procedure for treating most anxiety disorders
    • Almost always used with exposure-based treatments
    • Coping Cat: decrease negative thinking, increase active problem solving, and a functional coping outlook
    • Skills training and exposure combat problematic thinking
    • Computer-based CBT has also been shown to be effective

• Family Interventions

  • • Child-focused treatments may have spillover effects into the family
    • Greater parental involvement
    − Modeling and reinforcing coping techniques
    − Inclusion of parental anxiety-management strategies
    − Inclusion of parent skills training
    • Family treatment for OCD
    − Provides education about the disorder
    − Helps families cope with their feelings

• Medications

  • Medications can reduce symptoms, especially for OCD
    − The most common and effective medications are selective serotonin
    reuptake inhibitors (SSRIs), especially for OCD
    • Medications are most effective when combined with CBT
    • CBT is the first line of treatment