10-27-04

1. 10-27-04 • Questions • Handouts • Childhood Anxiety Disorders • History • Descriptions, Definitions, and Diagnostic Indicators • Prevalence • Etiology • Comorbidity • Prevention and Intervention • The Future • Cases

2. Childhood Anxiety Disorders Underreported and Underdiagnosed Or Overlooked and Misjudged

3. Childhood Anxiety Disorders • What Are They? • Anxiety disorders widely recognized as among the most common disorders affecting children and adolescents. • Commonly present as part of a complex picture. • Not well understood in children and adolescents.

4. Childhood Anxiety Disorders • History • Almost 100 years of case studies of childhood fears; “Little Hans” (1909), “Albert”(1920), “Peter”(1924). • However, prior to DSM-III (1980),fears and anxiety reactions in children ignored in classification systems. • Subclinical fears studied as part of normative development.

5. Childhood Anxiety Disorders • Psychopathological phobic reactions appeared in DSM (1952) as psychoneurotic reactions. • DSM-II (1968) changed to phobic neuroses and overanxious reaction was listed as a distinct diagnostic category for children. • DSM-III(1980) and DSM-III-R (1987) first attempts to delineate developmentally appropriate criteria for phobias and other anxiety disorders in children/adolescents.

6. Childhood Anxiety Disorders • SAD, Avoidant disorder of childhood and adolescence, and OAD listed as three distinct anxiety disorders in childhood. Thus a child could be diagnosed with one of these three types of anxiety disorders plus adult anxiety disorders. • DSM-IV (1994) Avoidant Disorder and OAD deleted with only SAD retained as a child or adolescent anxiety disorder.

7. Childhood Anxiety Disorders • In DSM-IV and DSM-IV-TR, the following diagnoses could be made for children and adolescents: • SAD. GAD, OCD, agoraphobia, panic disorder, specific phobias, social phobia, PTSD, acute distress disorder, and anxiety states due to medical disorder or substance abuse. • SAD=“excessive anxiety or fear concerning separation from home or from those to whom the child is attached” (Chapter 6, M & B, p.283).

8. Childhood Anxiety Disorders • What does SAD “look like” ? • mild, moderate, severe • most often diagnosed in prepubertal children • 5-8 year olds, fears of harm to attachment figures. • 9-12 year olds, distress at time of separation. • 13-16 year olds, somatic complaints and school refusal. • one-third concurrent with GAD, one third comorbid with depressive disorder (M & B),

9. Childhood Anxiety Disorders • Social Phobia=“marked and persistent fear of one or more social or performance situations in which person fears embarrassment may occur” (Chapter 6, M & B, p.285) • What does social phobia “look like” ? • most often appears in adolescence • negative self-focus and self-deprecation • higher levels of depressed mood • one study reports =# of boys and girls • most common anxiety disorder in adults • limited # of studies with children

10. Childhood Anxiety Disorders • OCD=“recurrent and intrusive obsessions and compulsions that are time-consuming (>1 hour per day) cause either marked distress for an individual or significant impairment in functioning”. (APA, 1994) • What does OCD look like? • in 90% of children with OCD, symptom patterns change over time • 50-60% of children with OCD have severe impairment in global functioning • mean age of onset 10-12.5 years of age • onset appears earlier in males than females • high incidence of OCD in children and adults with Tourette’s disorder

11. Childhood Anxiety Disorders • Specific Phobia=“marked and persistent fear of circumscribed objects or situations” (Chapter 6, M&B, p289). • What does specific phobia (formerly simple phobia) “look like” ? • persisted for 6 months • common phobias= height, darkness, loud noises, injections, dogs, etc. • children’s responses can be cognitive, behavioral, and physiological • some phobias usually appear before age 7 and some fit in with normal subclinical fears in children

12. Childhood Anxiety Disorders • GAD=the essential feature is overwhelming anxiety and worry about a lot of things, occurring most days, and persisting at least 6 months (Chapter 6, M & B, p292). • What does GAD look like? • excessive and unrealistic worrying observed in 95% of a clinic sample of GAD children • morbidly self-conscious • frequent worries are: grades, tests, natural disaster, future performance, being bullied • intensity of worries a differential feature • begins at any age (one study reporting GAD in a 4 year old) • high rate of concurrent disorders

13. Childhood Anxiety Disorders • Panic Disorder=“ the occurrence of at least one unexpected panic attack, followed by a minimum of 1 month of any one (or more) of the following: (Chapter 6, M & B, p. 294) persistent fear of future attacks, worry about what the attack meant, or a significant change in behavior related to the attacks.

14. Childhood Anxiety Disorders • What does panic disorder “look like” ? • Without agoraphobia- • With agoraphobia- • lack of information regarding age and gender patterns • panic attacks and panic disorder occur more frequently in adolescents • more common among females than males • Prevalence • Fonaggy et.al. (2002) reported in epidemiology study 8-12% for 4-20 year olds, In Chapter, 6 M & B varied reports, >10% in 11 studies, 12-20% in 4 of 5 large survey studies, much lower for 792 11 year olds, increased when reassessed at age 15,

16. Resources • Barrett & Ollendick (2004) • Mash & Barkley (2003) • Finaggy, P., Target, M., Cottrell, D., Phillips, J., Kurtz, Z. (2002). What works for whom? New York: Guilford Press. • Kaufmann, J. A. (2005). Characteristics of emotional and behavioral disorders of children and youth, 8th edition. Upper Saddle River, New Jersey: Pearson, Merrill, Prentice-Hall. • Wicks-Nelson, R. & Israel, A. C. (2003). Behavior disorders of childhood, 5th edition. Upper Saddle River, New Jersey: Prentice-Hall