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Chapter 7

Chapter 7 Anxiety Disorders

Course Code
Elizabeth Hayden

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Chapter 7: Anxiety Disorders
One of the most common mental health problems in young children, with lifetime prevalence estimates
between 8% and 30%
Often go unnoticed and untreated due to frequent occurrence of fears and anxiety during normal
development, invisible nature of many symptoms, and the fact that anxiety is not nearly as damaging to other
people or property as are conduct problems
Description of Anxiety Disorders
Anxiety mood state characterized by strong negative emotion and bodily symptoms of tension in which the
child apprehensively anticipates future danger or misfortune
o Two key features of anxiety strong negative emotion and an element of fear
Children who experience excessive and debilitating anxieties are said to have anxiety disorders
Anxiety becomes a serious problem when children experience fears beyond certain age, in situations that pose
no real threat or danger, to an extent that seriously interferes with daily activities
o This pattern of self-defeating behaviour is known as neurotic paradox
Anxiety involves an immediate reaction to perceived danger or threat a reaction known as fight/flight
o Effects are aimed at escaping potential harm, either by confronting the source of danger (fight) or by
evading it (flight)
Symptoms of anxiety are expressed through three interrelated response systems: the physical system, cognitive
system and behavioural system
o Physical system when a person perceives/anticipates danger, the brains sends messages to the
sympathetic, producing many important chemical and physical effects that mobilize the body for action:
Chemical effects adrenaline and noradrenaline are released from the adrenal glands
Cardiovascular effects heart rate and strength of heart beat increase, readying body for action
by speeding up blood flow and improving delivery of oxygen to tissues
Respiratory effects speed and depth of breathing increase, which brings oxygen to the tissues
and removes waste, producing feelings of breathlessness, choking or smothering, or chest pains
Sweat gland effects sweating increases
Other physical effects pupils widen to let in more light which leads to blurred vision, salivation
decreases, decreased activity in digestive system may lead to nausea and a heavy feeling in the
stomach, muscles tense in readiness for flight or fight, leading to subjective feelings of tension,
aches and pains, and trembling
o Cognitive system activation of fight/flight response produces immediate search for potential threat,
often leading to subjective feelings of apprehension, nervousness, difficulty concentrating, and panic
o Behavioural system urges that accompany the response are aggression and a desire to escape the
threatening situation
It is important to distinguish anxiety from two closely related emotions fear and panic
o Fear is an immediate alarm reaction to current danger or life-threatening emergencies
Although fear and anxiety have much in common, fear reaction differs both psychologically and
biologically from the emotion of anxiety
Fear is a present-oriented emotional reaction to current danger marked by a strong escape
tendency and an all-out surge in the sympathetic nervous system whereas anxiety is a future-
oriented emotion characterized by feelings of apprehension and lack of control over upcoming
events that might be threatening
o Panic is a group of physical symptoms of the fight/flight response that unexpectedly occur in the
absence of any obvious threat or danger
Normal fears, anxieties, worries and rituals:
o Various types of anxiety are evident by age 4, and about 25% of parents report that their child is too
nervous, fearful, or anxious
o Most frequent symptoms of anxiety in normal samples are separation anxiety, test anxiety, overconcern
about competence, excessive need for reassurance, and anxiety about harm to a parent
o Process of worry serves an extremely useful function in normal development, in moderate doses

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o Ritualistic, repetitive activity is extremely common in young children, including preferences of sameness
in environment, rigid likes/dislikes, awareness of minute details or imperfections in toys or clothes, etc.
Anxiety disorders in DSM-IV are divided into nine categories that closely define the types of reaction and
avoidance each discussed later in the chapter
Separation Anxiety Disorder
When anxiety persists for at least 4 weeks and is severe enough to interfere with normal daily routines such as
going to school, the child may have a separation anxiety disorder
Children with separation anxiety disorder (SAD) display age-inappropriate, excessive, and disabling anxiety
about being apart from their parents or away from home
o Younger children vague feelings of anxiety or repeated nightmares about being kidnapped or killed, or
about the death of a parent, and frequently display excessive demands for parental attention
o Older children difficulty being alone in a room, sleeping alone, running errands, going to school, and
may have fantasies of illness, accidents, kidnapping, or physical harm
o Children with SAD fear new situations and may display physical complaints
Prevalence and comorbidity
o SAD is one of the two most common anxiety disorders to occur during childhood, found in about 4
10% of all children
o Common in both boys and girls, but more prevalent in girls
o More than two-thirds of children with SAD have another anxiety disorder, and about half develop a
depressive disorder following the onset of SAD
Onset, course and outcome
o SAD has the earliest reported age of onset (7 to 8 years) and youngest age of referral
o Generally progresses from mild to severe
o Often occurs after child has experienced major stress, such as moving to a new neighborhood, death or
illness in the family, etc.
o Symptoms of SAD may also fluctuate over the years as a function of stress and transitions in the child’s
o SAD persists into adulthood for more than one third of children and adolescents
More likely to experience relationship difficulties, other anxiety disorders and mental health
problems, and functional impairment in their social/personal lives
School reluctance and refusal
o School refusal behaviour is defined as the refusal to attend classes or difficulty remaining in school for
an entire day
o Equally common in boys and girls, and occurs most often between the ages of 5 and 11 years
o Can occur at any time and may have a sudden onset at a later age
Generalized Anxiety Disorder
People with generalized anxiety disorder (GAD) experience excessive and uncontrollable anxiety and worry
about many events or activities on most days
Can be episodic or almost continuous
Often worrier is unable to relax and has physical symptoms such as muscle tension, headaches or nausea; other
symptoms may include irritability, a lack of energy, difficulty falling asleep, and restless sleep
In other anxiety disorders, anxiety converges on specific situations or objects, such as separation, social
performance, animals or insects, or bodily sensations in contrast, the anxiety experienced by children with
GAD is widespread and focuses on a variety of everyday life events
Generalized worry about minor events such as what to wear or what to watch on TV distinguishes children with
GAD from those with other anxiety disorders
Children with GAD are often self-conscious, self-doubting, and worried about meeting others’ expectations –
worry may lead to significant interpersonal problems
For children with FAD, one “crisis” is followed by another in a never-ending cycle the uncontrollable nature of
the worry is an important clinical feature of GAD
Diagnosis of GAD requires at least one somatic symptom frequently identified by a doctor as a result of a
child’s physical complaints that involve muscle tension and agitation, rather than the heart rate increases and
sweating that characterize other anxiety disorders

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o Headaches, stomach aches, muscle tension, and trembling are among the most commonly reported
Prevalence and comorbidity
o Found in 3% to 6% of all children
o In general, the disorder is equally common in boys and girls with a slightly higher prevalence in older
adolescent females
o Children with GAD have a high rate of other anxiety disorders and depression
o For younger children, co-occurring SAD and ADHD are most common
o Older children with GAD tend to have specific phobias, panic disorder, and major depression, as well as
impaired social adjustment, low self-esteem, and an increased risk for suicide
Onset, course, and outcome
o Average age of onset is around 10 14 years
o Severe generalized anxiety symptoms persist over time
Specific Phobia
Many children have specific fears that are mildly troubling, and they come and go rapidly until about age 10, and
rarely require special attention
However, if 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 specific phobia
Children with a specific phobia display a marked fear of clearly discernible objects or situations for at least 6
Show 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
According to evolutionary theory, human infants are biologically predisposed as a result of natural selection to
learn certain fears (Seligman, 1971)
o These fears are adaptive in an evolutionary sense
o Common types of specific phobias in young people include fears of animals or insects, fear of natural
events, fear of blood and injuries, and fear of specific situations such as flying in a plane, etc.
Prevalence and comorbidity
o About 4% to 10% of all children experience specific phobias at some time in their lives, and those with
this disorder tend to have multiple phobias
o Although comorbidity is frequent for children with specific phobias, it tends to be lower than for other
anxiety disorders
Onset, course and outcome
o Phobias involving animals, darkness, insects, blood and injury typically have their onset at 7 to 9 years of
age, which is similar to normal development
o However, even though fears and phobias decline with age, clinical phobias are more likely to persist
over time than are normal fears
o Specific phobias can occur at any age but seem to peak between 10 and 13 years of age
Social Phobia (Social Anxiety Disorder)
Social phobia, or social anxiety disorder marked and persistent fear of social or performance requirements
that expose them to scrutiny and possible embarrassment
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 frequently experience socially distressing events which they are unable to cope
effectively due to lack of social skills
In more severe cases, children develop a generalized social phobia fear most social situations, are afraid to
meet or talk with new people, avoid contact with anyone outside their family, and find it extremely difficult to
attend school, participate in recreational activities, or socialize
Anxiety associated with social phobia can be so severe that it produces stammering, sweating, upset stomach,
rapid heartbeat, or a full-scale panic attack
Prevalence, comorbidity and course
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