Class 16 (Childhood anxiety disorders pt 1)

What is anxiety?

A mood state characterized by strong negative emotion and bodily symptoms of tension, in which a person apprehensively anticipates danger or misfortune

What is Anxiety Disorder?

An excessive and debilitating chronic recurrence of anxiety, is among the most common childhood and adult disorders (approx 10-20% of kids)

What is the key difference between fear and worry in the context of anxiety?

Fear is present-oriented, focusing on immediate threats, while worry is future-oriented, involving concerns about potential dangers or uncertainties.

Anxiety disorders in the DSM-5 can be generally characterized into what 3 categories?

1. primarily worry - agoraphobia, separation anxiety disorder, generalized anxiety disorder

2. primarily fear - specific phobia, social phobia, selective mutism

3. blend of fear and worry - panic disorder

Fear is developmental and normal, but how does fear change throughout childhood?

Fear is a normative, with about 25% of parents reporting their children have many fears. Common fears at one age may become debilitating at another, but overall, the number of fears tends to decline over childhood.

What are Specific Phobias? And how is it expressed in children

A marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

• In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

How does a person typically respond to a phobic object or situation?

The phobic object or situation almost always provokes immediate fear or anxiety and is either actively avoided or endured with intense distress.

How does the intensity of fear in specific phobias compare to the actual danger of the feared object or situation?

The fear or anxiety is out of proportion to the actual danger posed and the person's sociocultural context.

What duration of time is needed to be considered a specific phobia?

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

What impact must a specific phobia have to be considered a disorder?

Must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Why are most normal fears not considered phobias?

They don’t cause significant distress or impairment in daily life

Prevalence rate of specific phobias

6-7% of kids ← the most common type of childhood anxiety disorder

What are some common specific phobias?

• heights

• enclosed spaces

• snakes

• dark

• spiders

• thunder/lightning

• dogs

• flying

What are some real-life examples of ways fear can be impairing?

• Cannot eat lunch in school cafeteria b/c of cockroach phobia

• Will not enter parts of home like laundry room or basement because of cockroach phobia

• Does not take public transportation b/c of cockroach phobia

• Does not visit family b/c of flying phobia

• Declines bridesmaid invite b/c of flying phobia

• Declines job on high floor of building b/c of fear of enclosed places (elevator)

• Does not get medically necessary MRI b/c of fear of enclosed places

Treating phobias: why do people avoid the things they fear?

• They believe they are in danger

• They don’t want to feel anxious — anxiety is aversive

• They don’t want others to notice they are anxious

• They don’t believe they can handle being anxious

• They have not handled the same situation well in the past

Why is avoidance a negatively reinforcing behavior?

Avoidance is a normal reaction, but because it is a reinforcement, it also exacerbates and maintains a phobia.

Extinction (operant conditioning)

When a previously reinforced behavior is no longer reinforced, the behavior will occur less frequently

What is the key to improving a phobia?

Extinguish the reinforcement associated with avoidance — if avoidance does not occur, anxiety will be experienced

Based on the “⇌ behaviors ⇌ thoughts ⇌ feelings ⇌” loop, what will change if we consciously modify an avoidance behavior?

We can improve thoughts which perpetuate anxiety and the anxious feelings themselves

Avoidant thoughts examples

• They believe they are in danger

• They don’t want to feel anxious (anxiety is aversive)

• They don’t want others to notice they are anxious

• They don’t believe they can handle being anxious

• They have not handled the same situation well in the past

Non avoidant thoughts examples

• The situation is not dangerous

• They tolerate the anxiety

• Others either don’t notice their anxiety or don’t care that they are anxious

• They are able to handle the situation even if they dislike it

What is the key component of effective treatments for phobias?

Exposure to a fear-provoking stimulus but limiting the anxiety-reducing response (aka avoidance)

How does prolonged exposure help individuals with phobias?

It leads to habituation, where the body acclimates to the feeling of anxiety over time.

Besides reducing anxiety, what is another benefit of exposure therapy for phobias?

It helps people form new beliefs about the feared situation and their ability to cope with it.

What is a fear and avoidance hierarchy?

An ordered list of situations, developed collaboratively with a therapist, in which a client experiences fear of phobic stimulus.

• each situation is rated in terms of how much fear it generates AND the lengths to which a client will go to avoid that situation

• used as a guide for exposures in therapy ← clients work from least feared to most feared stimulus

• individualized to client’s particular fears

How to effectively go through exposure therapy?

1. before exposure:

   1. identify scary thoughts about situation before exposure occurs

   2. rate level of distress

2. during exposure:

   1. continue to rate distress every 5 min

   2. do not try to distract self

   3. maintain objective awareness of physical symptoms and thoughts

3. continue exposure until anxiety goes down (3 or 4 on a scale of 10 is optimal, or 30-40 on a scale of 0-100)

4. after exposure: rate level of distress and evaluate scary thoughts again

What is more effective for exposure therapy: one long exposure or multiple short exposures?

One long exposure (e.g., 1 solid hour) is more effective than several short exposures (e.g., four 15-minute sessions).

What if we stop an exposure when someone is anxious? What will be reinforced?

Never stop an exposure before habituation occurs. Otherwise, all that is reinforced is the sense that the anxiety-producing stimulus is to be feared.

• most important rule of anxiety treatment

Where can exposure therapy happen?

• in vivo (done in life)

• in session (with therapist)

The goal of treatment is not ___?

to “get rid of anxiety”

The goal of treatment is ___?

For people to realize that even though anxiety is uncomfortable, the risks of anxiety are minimal.

What do these principles of anxiety treatment also apply to?

Other anxiety disorders

What is Social Phobia?

A marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others

• In children, the anxiety must occur in peer settings and not just during interactions with adults

The same criteria regarding active avoidance, distress, impairment as for Specific Phobias

Also known as social anxiety disorder

What are some examples of social phobia?

• social interactions (e.g. having a conversation, meeting unfamiliar people)

• being observed (e.g. eating or drinking)

• performing in front of others (e.g. giving a speech)

How is social phobia different from specific phobias in terms of development?

Social phobia has a clear developmental precursor (behavioral inhibition)

What is behavioral inhibition?

Behavioral inhibition is a temperament style evident in infancy, characterized by withdrawal or fear responses (e.g., crying, back arching, limb movement) when faced with novel or unfamiliar situations or people

How stable is behavioral inhibition over time, and how pervasive is it?

It remains stable across development as babies grow into children. It is pervasive across contexts.

What is behavioral inhibition a response to?

BI seems to be a generalized response to novelty, not the specific people or situations involved

What is the relationship between behavioral inhibition in infancy and social phobia later in life?

Developmental trajectory of BI: Infants with behavioral inhibition are 2x as likely to develop social phobia in middle childhood and 4x as likely in adolescence.

What biological factor is believed to cause behavioral inhibition?

Hyper-reactivity of the amygdala in response to novelty.

Is behavioral inhibition in infancy linked to parenting style or attachment?

No, there is no consistent association between parenting style or attachment and behavioral inhibition in infancy.

How do parents of behaviorally inhibited children typically respond?

Behaviorally inhibited children are more likely to have parents who are overprotective and limit their child’s autonomy, often trying to help them sidestep or avoid situations with the potential for distress.

Do anxious children evoke overprotective parenting, or does overprotective parenting cause anxiety?

Longitudinal research suggests that the emergence of childhood anxiety symptoms precede parental overprotection, meaning children’s behavior influences parental responses.

What does the phrase "development is transactional" mean in the context of behavioral inhibition?

It means that children play an active role in shaping their environment and the way others, including parents, respond to them.