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Chapter 7

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Western University
Psychology 2042A/B
Scott Wier

Child Psychology Chapter 7: Anxiety Disorders Introduction  Anxiety is one of the most common mental health problems in young people  Despite their early onset, high frequency, chronicity, and associated problems, anxiety disorders in children often go unnoticed and untreated  This may be due to the frequent occurrence of fears and anxiety during normal development, the invisible nature of many symptoms, and the fact that anxiety is not nearly as damaging to other people or property as are conduct problems  Many children who experience anxiety continue to display anxiety and other problems during adolescence and adulthood  Anxiety disorders have a more chronic course  The societal costs for clinically anxious youngsters are also substantial Description of Anxiety Disorders:  Anxiety: a mood based disorder characterized by strong negative emotion and bodily symptoms of tension in which the child apprehensively anticipates future danger or misfortune  Key features of anxiety – strong negative emotions and a element of fear  Children who experience excessive and debilitating anxieties are said to have anxiety disorders, which occur in many forms  Many youngsters with anxiety disorders suffer from more than one type, either simultaneously or at separate times during their development Description of Anxiety Disorders: Experiencing Anxiety  Anxiety is both expected and normal at certain ages and in certain situations  Anxiety often hits us when we do something important, and in moderate doses it helps us think and act more effectively  Anxiety is an adaptive emotions that readies children both physically and psychologically for coping with people, objects, or events that could be dangerous to their safety or well-being  Excessive, uncontrollable anxiety can be debilitating  When children experience fears beyond a certain age, in situations that pose no real threat or danger, to an extent that seriously interferes with daily activities, anxiety is a serious problem  Neurotic Paradox: a pattern of self-defeating behaviour that can become self- perpetuating  Fight/flight Response: an immediate reaction to perceived danger or threat  The symptoms of anxiety are expressed through three interrelated response systems: the physical system, the cognitive system, and the behavioural system  More than one may be evident in different children with the same anxiety disorder Description of Anxiety Disorders: Physical System  When a person perceives or anticipates danger the brain sends messages to the sympathetic nervous system, which produces the fight/flight response  The activation of this system produces many important chemical and physical effects that mobilize the body for action o Chemical Effects – adrenaline and noradrenaline released o Cardiovascular Effects – increase heart rate, blood flow, and oxygen delivery o Respiratory Effects – increased speed and depth of breathing o Sweat Gland Effects – increased sweating o Other Physical Effects – pupils dilate, salivation decreases, decreased activity of digestion system, and muscles tense  Overall fight/flight response produces general activation of the entire metabolism  This activation takes a lot of energy and he/she feels tired and drained after Description of Anxiety Disorders: Cognitive System  Produces immediate search for potential threat  For children it is difficult to focus on everyday tasks because their attention is consumed by a constant search for threat or danger  When these children cant fins proof of danger, they may turn their search inward  Activation of the cognitive system often leads to subjective feelings of apprehension, nervousness, difficulty concentrating, and panic Description of Anxiety Disorders: Behavioural System  Aggression and a desire to escape the threatening situation, but social constraints may prevent fulfilling either impulse  Avoidance is the very thing that perpetuates anxiety, despite the temporary feeling of relief  Avoidance behaviours and negatively reinforced  As children with anxiety disorders engage in more avoidance, carrying out everyday activities becomes exceedingly difficult Anxiety Versus Fear and Panic  Fear: an immediate alarm reaction to current danger or life-threatening emergencies  The fear reaction differs both psychologically and biologically from the emotion of anxiety  Fear is a present-oriented emotional reaction to current danger, marked by strong escape tendencies and an all-out surge in the sympathetic nervous system  In contrast, anxiety is future- oriented emotion characterized by feelings of apprehension and lack of control over upcoming events that might be threatening  Both warn of danger or distress  Only anxiety is frequently felt when no danger is actually present  Panic: a group of physical symptoms of fight/fight response that unexpectedly occur in the absence of any obvious threat or danger  The sensations themselves can feel threatening and may trigger further fear, apprehension, anxiety and panic Normal Fears, Anxieties, Worries, and Rituals  Emotions and rituals increase feelings of control  When the emotions and rituals become excessive, or occur in a developmentally inappropriate context, that they are chosen are of concern Normal Fears  Fears that are normal at one age can be debilitating a few years later  Whether or not a specific fear is normal also depends n its effect on the child and how long it lasts  The number and type of common childhood fears changes over time, with a general age-related decline in number  Girls tend to have more fears than boys at almost every age, they also rate themselves more intense and disabling than do boys  Fears show a general decline with age, come remain stable, and some increase Normal Anxieties  Anxieties are very common during childhood and adolescence  Most frequent symptoms of anxiety are separation anxiety, test anxiety, over concern about competence, excessive need for reassurance, and anxiety about harm to a parent  Younger children generally experience more anxiety symptoms than do older children, primarily about separation fro parents  Girls display more anxiety than boys, but the types of symptoms they experience are quite similar  Some specific anxieties decrease with age or stay stable  The disposition to be anxious may remain stable over time, even though the objects of children’s fears change Normal Worries  The process of worry serves an extremely useful function in normal development  In moderate doses, worry can help children prepare for the future  Worry is a central feature of anxiety  Children of all ages worry, but the forms and expressions change  Older children report a greater variety and complexity of worries and are better able to describe them than are younger children  These children do not necessarily worry more but they seem to worry more intensely  Worries about being around strangers, going to school, or having and things happen to the child or parents occur frequently in children with anxiety disorders  Worries over personal safety, doing a good job, and being embarrassed occur in both groups but more often in children with anxiety disorders Normal Rituals and Repetitive Behaviour  Ritualistic, repetitive activity is extremely common in young children  Normal ritualistic behaviour in young children include preference for sameness in the environment, rigid likes and dislikes, preference for symmetry, awareness of minute details or imperfections in toys or clothes and arranging things so they are “just right”  Rituals help young children gain control and mastery over their social and physical environment and make their world more predictable and safe  Routines fall into two distinct categories: repetitive behaviours and doing things “just right”  Similar procedures as those found in OCD  Findings suggest that the neuropsychological mechanisms underlying compulsive, ritualistic behaviour in normal development and those in OCD may be similar Anxiety Disorders According to DSM-IV-TR  Anxiety disorders in DSM-IV-TR are divided into categories: SAD, GAD, specific phobia, social phobia, OCD, PD, PD with agoraphobia, PTSD, and acute stress disorder Separation Anxiety Disorder  Separation anxiety is important for the young child’s survival and is normal at certain ages (7 months – preschool years)  Lack of separation anxiety at this age may suggest insecure attachment or other problems  When anxiety persists for at least 4 weeks and is severe enough to interfere with normal daily routines such as going to school or participating in recreational activities the child may have SAD  Young children may have vague feelings of anxiety or repeated nightmares about being kidnapped or killed, or about the death of a parent  Other children may have specific fantasies of illness, accidents, kidnapping, or physical harm  Young children with SAD frequently display excessive demands for parents attention by clinging to their parents and shadowing their every move  Older children may have difficulty being alone even at home, running errands, going to school or going to camp  Fear new situations and may display physical complaints  To avoid separation, they may fuss, cry, scream or threaten suicide if their parent leave  Parents, especially mothers become highly distressed  Over time, children with SAD may become increasingly withdrawn, apathetic, and depressed and are at risk for developing a variety of other anxiety disorders during adolescence Separation Anxiety Disorder: Prevalence and Comorbidity  One of the most common anxiety disorders to occur during childhood  Common in both boys and girls, more prevalent in girls Separation Anxiety Disorder: Onset, Course, and Outcome  SAD has the earliest age of onset (7-8) and youngest referral  Generally progresses from mild to severe  May being with restless sleep than to sleeping in bed with parents  Often occurs after a child has experienced major stress  Symptoms of SAD may also fluctuate over the years as a function of stress and transitions in the child’s life  May lose friends as a result of their repeated refusal to participate in activities away from home  Children with SAD are reasonably socially skilled and get along with others  School performance may suffer as a result of frequent absences  SAD persists into adulthood and adults are more likely than other to experience relationship difficulties, other anxiety disorder and mental health problems and functional impairment in their social and personal lives Separation Anxiety Disorder: School Reluctance and Refusal  Reluctant to go to school, and for a few, school may create so much fear and anxiety tat they will not go  These children can become literally sick with worry, let minor physical complaints keep them at home, or pretend to be ill  School Refusal Behaviour: the refusal to attend classes or difficulty remaining in school for an entire day  School refusal is equally common in boys and girls between the ages 5 and 11  Usually first occur during preschool, kindergarten, or first grade, and peak during the second grade  School refusal often follows a period at home during which the child has spent more time than usual with a parent or may follow a stressful event  Fear of school is really a fear of leaving parents but can occur for many reasons  These children have average or above average intelligence, suggesting it is not a difficult with academics that leads to this problem  A fear of school may be associated with submitting for the first time to authority and rules outside the home, being compared with unfamiliar children, and experiencing the threat of failure, and may be fear being ridiculed, teased, or bullied by other children  Academic or social problems may develop as a result of missed instruction and peer interaction  CBT is used Generalized Anxiety Disorder (GAD)  GAD: experience excessive and uncontrollable anxiety and worry about many events or activities on most days  For children with GAD, worrying can be episodic or almost continuous  Often unable to relax and had physical symptoms such as muscle tension, headaches, or nausea, and irritability, a lack of energy, difficult falling asleep, and restless sleep  Anxiety experienced by children with GAD is widespread and focuses on a variety of everyday life events  Focus their anxiety on many different things  Likely to pick up on every frightening event and related it to themselves  Always expect the worst possible outcome and underestimate their ability to cope with situations or events that are less then ideal  Thinking often consists of what if statements  Do not restrict their worries to frightening or catastrophic events; they also worry excessively about minor everyday occurrences  Often self-conscious, self-doubting, and worried about meeting others expectations  May lead to significant interpersonal problems  Children with GAD seek constant approval and reassurance from adults and fear people whom they perceive as unpleasant, critical, or unfair  They tend to set extremely high standards for their own performance and, then they fall short, they are highly self-critical  Continue to worry even when evidence contradicts their concern  Show an intolerance of uncertainty, which may result in impaired decision- making under conditions of uncertainty  One “crisis” is followed by another in a never-ending cycle  A diagnosis of GAD in children requires at least one somatic symptom  Chronic worry may function as a type of cognitive avoidance that inhibits emotional processing  Because they are so busy thinking about upcoming problems they may not produce images of threat that elicit intense negative emotion and automatic activity  Chronic worry may serve the same dysfunctional purpose as behavioural avoidance does in children with specific phobias Generalized Anxiety Disorder: Prevalence and Comorbidity  Slightly higher prevalence in older adolescent females  High rate of other anxieties and depression  For younger children, co-occurring SAD and ADHD are most common  Older children with GAD tend to have specific phobias and major depression impaired social adjustment, low self-esteem, and an increased risk for suicide Generalized Anxiety Disorder: Onset, Course, and Outcome  Average age of onset for GAD is 10-14 years  Older children present with a higher total number of symptoms and report higher levels of anxiety and depression then younger children, but symptoms diminish with age Specific Phobia  Many children have specific fears that are mildly troubling, come and go rapidly until about age 10 and rarely require special attention  If the child’s fear occurs at an inappropriate age, persists, is irrational or exaggerated, leads to avoidance of the object or event, and causes impairment in normal routines it is called a phobia  Marked fear for at least 6 months  Specific Phobia: an extreme and disabling fear of objects or situations that in reality pose little or no danger or threat and go to great lengths to avoid them  They experience extreme fear or dread, physiological arousal to the feared stimulus, and fearful anticipating and avoidance when confronted with the object of their fear  Their thinking usually focuses on threats to their personal safety  Anticipatory anxiety is also common  Children are constantly on the lookout for the feared stimulus and go to great lengths to avoid contact  Children’s beliefs regarding the danger of the feared stimulus are likely to persist despite evidence no danger exists or efforts to reason with them  Children often do not recognize that their fears are extreme and unreasonable  Certain fears are more likely than others to develop in children  Human infants are biologically predisposed as a result of natural selection to learn certain fears rather than others  Most children’s phobias have sources of natural danger during human evolution  Most common and most heritable specific phobia in children is a fear of animals, particularly dogs, snakes, insects, and mice  DSM categorizes specific phobias into five subtypes: o Animal o Natural Environment o Blood-Injection Injury o Situational o Other Specific Phobia: Prevalence and Comorbidity  Very few of these children are referred for treatment  Specific phobias are common in girls than boys  The most common co-occurring disorder fro children with a specific phobia is another anxiety disorder  Comorbidity tends to be lower than for other anxiety disorders Specific Phobia: Onset, Course, and Outcomes  Phobias have their onset at 7-9 years which is similar to normal development  Clinical phobias are more likely to persist over time than are normal fears even though both decline with age  Specific phobias can occur at any age but seem to peak between 10-13 years Social Phobia (Social Anxiety)  Social Phobia: marked and persistent fear of social or performance requirements that expose them to scrutiny and possible embarrassment  They go to great lengths to avoid these situations, or they may face the challenge with great effort  Children with social phobias continue to shrink from people they don’t know  When in the presence of other children or adults, they blush, fall silent, cling to their parents, or try to hide  Youngsters with social phobias may feel anxious about the most mundane activities  Their most common fear is doing something in front of other people  Youngsters with social phobias are more likely than other children to be highly emotional, socially fearful and inhibited, sad, and lonely  They frequently experience socially distressing events with which they are unable to cope effectively in part related to a lack of social skills  These children want to be liked by other people, but fear of humiliation because they cannot form the relationships they desire  In the most severe cases, children develop a generalized social phobia  Anxiety associated with social phobia can be so severe that it produces stammering, sweating, upset stomach, rapid heart beat, or a full scale panic attack  Believe that their visible physical reactions will expose their hidden feelings of inadequacy, which makes them more anxious Social Phobia: Prevalence, Comorbidity, and Course  Affecting slightly more girls than boys  Girls experience more social anxiety because they are more concerned with social competence than are boys, and attach greater importance to interpersonal relationships  Most common secondary diagnosis for children referred for other anxiety disorders  Any cases of social phobia are overlooked because shyness is common in our society  Children and adolescents with a social phobia have another anxiety disorder  Adolescents with a social phobia suffer from major depression. They may also use alcohol and other drugs as a form of self-medication to reduce their anxiety in social situations  Social phobias are extremely rare in children under the age of 10, and generally develop after puberty, most common age of onset in early-mid adolescence  The symptoms of anxiety they most frequently report include fears of public speaking, blushing, excessive worry about past behaviour, an self consciousness  The prevalence of social phobia appears to increase with age  One characteristic in early adolescence that has been shown to predict symptoms of social anxiety is perception of not being accepted by peers Selective Mutism  Selective Mutism: fail to talk in specific social situations, even thought they may speak loudly and frequently at home or in other settings  This disorder is uncommon  Although not included as an anxiety disorder, selective mutism has many factors in common with the anxiety disorders  Meet diagnostic criteria for a social phobia in ways other than their reluctance to speak and have also been diagnosed with a social phobia during their lifetime  Selective mutism may be an extreme type of social phobia rather than a unique disorder  Oppositional features and nonverbal social engagement occur in selective mutism  May also display developmental delay, language impairments or auditory processing deficits  In some cases trauma played a role and not talking was a self-protective response  Behavioural and cognitive behavioural interventions have been used to help children with selective mutism Obsessive-Compulsive Disorder (OCD)  OCD: an unusual disorder of ritual and doubt  Experience recurrent time-consuming and disturbing obsessions and compulsions  Obsessions: persistent and intrusive thoughts, ideas, impulses, or images  Obsessions are much more than heightened worries about everyday problems  They are excessive and irrational, and are focused on improbable or unrealistic events, or on greatly exaggerated real-life events  The most common obsessions in children focus on contamination, fears of harm to self or others, or concerns with symmetry and exactness, while in adolescence, sexual, somatic, and religious preoccupations also become more common  Children go to great lengths to try to neutralize them with another action, known as a compulsion  Compulsions: repetitive, purposeful, and intentional behaviours or mental acts that are preformed in response to an obsession  Multiple compulsions are the norm, the most common being excessive washing and bathing repeating checking, touching, counting, hoarding, and ordering or arranging  The belief that drives OCD are superstitions and rituals  Most children with OCD have multiple obsessions and compulsions, and certain compulsions are commonly associated with specific obsessions o Cleaning rituals – contamination obsession o Concern with dirt – chemical or environmental contamination o Counting – concern for harm o Symmetry – compulsions for arranging and ordering  Most children over age 8 persist in their obsessions or compulsions even though they recognize them as excessive and unreasonable  OCD is extremely resistant to reason, even when the child recognizes the “silliness” of the routines  Children with OCD often involve family members in their rituals  Compulsions are intended to neutralize or reduce the anxiety and tension of the obsessions, or to prevent some dreaded event or situation from happening  May provide temporary relief from anxiety  Obsessions and rituals makes it extremely difficult to focus on anything else  Activities of children with OCD are reduced, and health, social and family relations, and school functioning can be severely disrupted  Many children try to make or hide their rituals  As the rituals become more elaborate and time-consuming, they become increasingly difficult to conceal  Suppression commonly has a rebound effect, with increased symptoms once the child is in a safe place Obsessive-Compulsive Disorder (OCD): Prevalence and Comorbidity  Lifetime prevalence of OCD in children and adolescents  Twice as common in boys than girls  Most common comorbidities are other anxiety disorders, depressive disorders and disruptive behaviour disorders  Substance-use disorders, learning disorders, and eating disorders as well as vocal and motor tics Obsessive-Compulsive Disorder (OCD): Onset, Course, and Outcome  Mean age of onset of OCD is 9-12 years with two peaks, one in early childhood and another in early adolescence  Children with an early onset of OCD are more likely to have a family history of OCD suggesting a greater role of genetic influences in such cases  These children may have prominent motor patterns engaging in compulsions without obsessions and displaying odd behaviours  Young children typically have obsessions that are more vague than those of older children, and are less likely to feel that their obsessions are abnormal  Most children over age 8 are aware that their obsessions are abnormal, and they are usually uncomfortable talking about them  Predictors of poor outcome include a poor initial response to treatment, a lifetime history of tic disorder, and parental psychopathology at the time of referral.  Chronic disorder Panic: Panic Attacks  Panic Attack: a sudden and overwhelming period of intense fear or discomfort that is accompanied by four or more physical and cognitive symptoms characteristic of the fight/flight response  Usually, a panic attack is short, with symptoms reaching maximal intensity in 10 minutes or less  Panic attacks are accompanied by an overwhelming sense of imminent danger or impending doom, and by an urge to escape  They can occur several times a week or month  Symptoms are not physically harmful or dangerous  Panic attacks are extremely rare in young children, they are common in adolescents  Increasing rates of panic were related to pubertal development, not to increasing age  Adolescence is the peak time for the onset of the disorder, the physical changes that take place around puberty seem critical to the occurrence of panic  Stress can increase production of adrenaline and other chemicals that may produce physical symptoms of panic  Breathing a little too fast can also produce symptoms and notice these sensations far more readily Obsessive-Compulsive Disorder (OCD): Panic Disorder  Some adolescents who experience repeated severe panic attacks have no other symptoms  Others have a progression of distressing symptoms and develop a panic disorder  Panic Disorder (PD): display recurrent unexpected attacks followed by at least 1 month of persistent concern about having anther attack, constant worry about the consequences, or a significant change in their behaviour related to the attacks  This types of worry is refer
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