ANXIETY IN

CHILDREN
What is Normal?
10 – 20% of children and adolescents suffer a diagnosable anxiety
disorder
Many more children suffer with symptoms that do not meet diagnostic
criteria (Walkup et al, 2008)
~40% of grade school children have fears of separation from a parent
~40% of children aged 6 – 12 years have 7 or more fears that they find
troubling
~30% of children worry about their competence and require
considerable reassurance
~20% of grade school children are fearful of heights, are shy in new
situations, or are anxious about public speaking and social
acceptance (Bell-Dolan et al, 1990)
Girls report more stress than boys – may be an artifact of social
expectations
Most of these worries and stresses are outgrown or recede as children
mature and develop
Anxiety can be your friend
 Distinguishing Normal from Pathological

1. Object: Is this something a child of this age should be

worrying about?
2. Intensity: Is the degree of distress unrealistic given the
child’s developmental stage and the object/event?
3. Impairment: Does the distress interfere with the child’s
daily life?
- Social functioning: unable to make friends
- Academic functioning: failing classes
- Family functioning: creating conflicts, limiting family
choices
4. Ability to Recover/Coping Skills: Is the child able to
recover from distress when the event is not present?
- Tend to worry about future occurrences of event/object
- Distress occurs across multiple settings
Normal Fear and
Worry
× Common in normal children
× The clinician must distinguish developmentally
normal from abnormal
× Infants
× Fear of loud noises
× Fear of being startled
× Fear of strangers (around 8 – 10 months)
× Toddlers
× Fears of imaginary creatures
× Fears of darkness
× Normative separation anxiety
× School-age Children
× Worries about injury and natural events (e.g.,
storms, lightening, earthquakes, volcanoes)
× Children who are characterized as confident
and eager to explore novel situations at 5
years are less likely to manifest anxiety in
childhood and adolescence
× Children who are passive, shy, fearful, and
avoid new situations at 3 and 5 years are more
likely to exhibit anxiety later in life (Caspi et al,
1995)
× School Age Children (continued)
× In general, girls tend to endorse more
anxiety symptoms than boys
× Younger children are more likely to
experience anxiety symptoms than older
children
× Anxious children interpret ambiguous
situations in a negative way and may
underestimate their competencies
(attribution bias)
× The most common anxiety disorders in
middle childhood are Separation Anxiety,
GAD, and Specific Phobias
× Adolescents
× Fears related to school
× Fears related to social competence
× Fears related to health issues
Clinical Presentation
× Children with anxiety disorders may
present with fear or worry but may not
recognize their fears as unreasonable
× Younger kids often cannot articulate their
feelings, and so we often see physical
symptoms presenting first, which include:
× Headaches, upset stomach or nausea,
increased heart rate, diarrhea or
constipation, sleep disturbance, increased
vulnerability to common viruses, tightness
in chest, tight neck or back, appetite change,
fatigue & exhaustion
What To Look For
× Physical complaints
× Sleep (early/middle insomnia, repeated visits to
parent’s room)
× Change in eating
× Avoidance of outside and interpersonal activities
(school, parties, camp, slumber parties, safe strangers)
× Excessive need for reassurance (new situations,
bedtime, school, storms, “is it bad?”)
× Inattention and poor school performance
× Not necessarily pervasive (some areas of function
remain intact)
× Explosive outbursts
Physical Symptoms (Provoked and
Non-Provoked)
Anxious children listen to their bodies (too much!)
Headache & stomachache
Sick in the morning
Frequent urge to urinate or defecate
Shortness of breath
Chest pain, tachycardia
Sensitive gag reflex/fear of choking or vomiting
Difficulty swallowing solid foods
Dizziness
Tension/exhaustion
Derealization/depersonalization
Avoidance to present physical symptoms
Clinical Presentation:
Separation Anxiety Disorder
× Excessive fear when separated from home or attachment
figures
× Can be seen before separation or during attempts at
separation
× Excessive worry about their own or their parents’ safety
and health when separated
× Symptoms include difficulty sleeping alone, nightmares
with themes of separation, somatic complaints, school
refusal
× Commonly, the earliest age of onset among anxiety
disorders
× Gender ratios are generally equal
× These children often come from singe-parent and low SES
homes
× A nonspecific precursor to a number of adult psychiatric
conditions, including depression as well as any anxiety d/o
Clinical Presentation:
Phobias
× Fear of a particular object or situation which is
avoided or endured with great distress
× More than one phobia is common (does not in
and of itself constitute a diagnosis of GAD)
× Adolescents and adults typically recognize that
the fear is unreasonable; children often do not
× Avoidance is key
× Generally begins in childhood
Clinical Presentation:
Generalized Anxiety Disorder
× Characterized by chronic, excessive worry in a number
of areas (e.g., schoolwork, social interactions, family,
health/safety, world events, and natural disasters)
with at least one associated somatic symptom
× Affected children are often perfectionistic, seek
reassurance, and struggle more than is evident to
parents and teachers
× Worry is most often present and not limited to a
specific situation or object
× These kids don’t just worry about performance and
social concerns (e.g., social phobia) – these kids worry
about the quality of their relationships rather than
experiencing embarrassment or humiliation in social
situations
Clinical Presentation: Social
Phobia
Characterized by feeling scared or uncomfortable in one or more
social settings (discomfort with unfamiliar peers and not just
unfamiliar adults) or performance situations (e.g., sports, music)
Associated with a fear of scrutiny and of doing something
embarrassing in social settings such as classrooms, restaurants,
or extracurricular activities
May have difficulty answering questions in class, reading aloud,
initiating conversation, talking with unfamiliar people, and
attending parties and social events
The anxiety with social phobia dissipates when away from a
social situation; unlike GAD where the anxiety is persistent
90% of children with Selective Mutism have been shown to meet
criteria for Social Phobia (SM should probably be viewed as a
specific type of Social Phobia)
Differential with PDD
Clinical Presentation:
Panic Disorder
× Recurrent episodes of intense fear that occur
unexpectedly (cued or uncued)
× Panic disorder vs. panic attacks
× Cued panic attacks can occur with any anxiety
disorder, or independently, and are common
among adolescents
× Fear of death or going crazy
× Uncommon before the peri-pubertal period
(adult retrospective studies have shown that sx
commonly begin in adolescence or young
adulthood)
× The peak age of onset of panic d/o is age 15 – 19
Clinical Presentation:
Obsessive-Compulsive
Disorder
× Most patients experience both obsessions
and compulsions
× Changes in symptoms and in intensity over
time
× Parents often become unwilling
collaborators in the illness
× Symptoms commonly exist for years before
reaching clinical attention
Trauma
× Any or all anxiety symptoms

× Symptoms may wax and wane

× Symptoms typically worsen when

confronted with reminders or situations
reminiscent of the trauma
Etiology
× Behavioral Inhibition
× Genetic
× Neuroimaging
× Neurotransmitter
× Neuroendocrine
× Learned Responses
× Attachment Research
× Psychoanalytic
Behavioral Inhibition
× “Behavioral Inhibition” (a lab-based
temperamental construct) is defined as the
tendency to be unusually withdrawn or timid and
to show fear and withdrawal in novel and/or
unfamiliar social and nonsocial situations
× Those who are withdrawn in social situations only
are considered “shy”
× Both behavioral inhibition and shyness are
associated with anxiety disorders in both children
and adults
× The tendency to approach or withdraw from
novelty is an enduring temperamental trait
Behavioral Inhibition (2)
× Kids with BI show a lot of physiological signs often
associated with anxiety, including enhanced
sympathetic nervous system tone (e.g., elevated
resting heart rate and salivary cortisol), increased
tension in the vocal cords and larynx, and elevations
in urinary catecholamines (Kagan et al, 1988)
× Kids with BI are more likely to have multiple
psychiatric disorders and two or more anxiety
disorders (especially Avoidant D/O, Separation
Anxiety D/O, and Agoraphobia)
× Kids with BI have a higher risk of panic is they age
(Smoller et al, 2005)
× Thus, Behavioral Inhibition is a risk factor for the
development of anxiety disorders in children
× BI is also heritable
Neurobiology of Anxiety
× Systems involved in sensing and responding to
threat are redundant and involve numerous brain
systems to promote survival
× Reticular Activating System (a network of
ascending, arousal-related neural systems)
× Locus coeruleus NA mobilizes in response to
real or perceived threat
× Dorsal raphe 5HT mediates the locus
coeruleus
× Lateral dorsal tegmentum cholinergic &
mesolimbic & mesocortical DA neurons affect
brain sensitivity and interpretation of threat
Limbic System (1)
× Anxiety is believed to recognized at the amygdala
× The hippocampus is the storage site of cognitive
and emotional memories and is very sensitive to
stress
× Threat alters the ability of the hippocampus and
connected cortical areas to store certain types of
cognitive information (verbal) but not nonverbal
information
× Many of the cognitive distortions that are
associated with anxiety disorders may be related to
anxiety related alterations in the tone of the
hippocampus and associated cortical areas
Limbic System (2)
× Neuronal systems are capable of making
remarkably strong associations between paired
cues (e.g., growl of a tiger and threat)
× This capacity of the brain to generalize from a
specific event renders humans vulnerable to
false associations and over generalizations
× Once these specific cues (e.g., snakes) become
linked with limbic mediated responses (e.g.,
anxiety), it is the sensitivity of the individual’s
stress response system which determines if the
alarm system (anxiety) will be activated
Genetics of Anxiety
There are thousands of genes which, if abnormal, could
result in altered development or functioning of
neurotransmitter and neuroanatomical regions involved in
regulating anxiety
Strong familial trends in anxiety disorders
No clear data support a specific genetic etiology for
childhood anxiety disorders
Heritability estimates of Panic Disorder (48%) and
Generalized Anxiety Disorder (32%) exist (Hettema et al,
2001)
Given these estimates, it is clear that genes account for
only some portion of the increase in risk among family
members of an affected individual
Environmental factors (e.g., perinatal exposures and
developmental experience) must play a major role
Learned Responses
× Most specific fears (phobias) are related to paired
or mispaired internalization of cues with anxiety
from previous experience
× Some anxieties may involve genetically fixed
patterns developed over eons of evolution (e.g.,
snakes)
× During infancy and childhood children mirror their
caretakers’ responses when interpreting internal
states of pain, arousal, and anxiety
× Over time children may come to label a host of
external cues as potentially threatening and certain
internal sensations as fearful; this is the
hypothesized mechanism of GAD, specific phobias
(Kendall and Ronan, 1990), and some types of
PTSD (Main and Hesse, 1990)
Etiologic Example: OCD
× Genetic: Likely a vulnerability is genetically
transmitted, based upon increased concordance
rates among monozygotes vs. dizygotes and
increased rates among 1st degree relatives of
probands
× Neurophysiology: Increased metabolism in
orbitofrontal and caudate systems (e.g., hyperactive
caudate; PET scans); abnormalities supposed in
circuits linking basal ganglia and frontal lobes
(Baxter et al, 1992)
× Neuroendocrine: Individuals with OCD have shown
elevated levels of Oxytocin (behavioral effects of
which typically contribute to cognitive, grooming,
affiliative, and reproductive behaviors in animals)
Attachment
Secure
Insecure Resistant -
Hyperactivating
Insecure Avoidant - Inhibited
Disorganized - No adaptive strategy
× Frightening, unpredictable
parents
Attachment
Research
× Insecure attachment may be a risk factor for the
development of childhood anxiety disorders
× An attachment study showed that 80% of
children born to insecure mothers were
classified as insecurely attached children
× The presence of behavioral inhibition does not
seem to increase the risk of being insecurely
attached and vice versa
The Impact of Trauma Is Developmentally
Sensitive
Affect Regulation

Affect Dysregulation Measures

80

60

40

20

0
Alexythymia (TAS) =or>74 High Dissociators (DES) Suicide Attempts
=or>20

CSA ASA NCC Cloitre et al., 1997

The Impact of Trauma Is Developmentally
Sensitive
Interpersonal Functioning
Inventory of Interpersonal Problems

70.0

52.5

35.0

17.5

.0
Assertive Sociable Submissive Responsible Intimate Control Cloitre et al., 1997
CSA ASA NCC
Psychoanalytic
× The key idea is that phobias develop as a
defense against anxiety which is produced
by repressed id impulses.

× Anxiety is displaced from the id impulses to

a fear object that is linked symbolically (and
generally more acceptable).

× By avoiding the phobic object, one avoids

dealing with repressed childhood conflicts.
Epidemiology

× Anxiety is the most prevalent mental health disorder

in children and teens
× Estimated at 6 – 20%
× Difficult numbers because subthreshold anxiety
(not meeting DSM criteria) can also cause
severe disability
× Developmental progression of anxiety disorders in
adulthood
× Untreated childhood anxiety typically continues
into adulthood
× Leads to an increased risk of depressive
disorders

 Albano, Chorpita, & Barlow (2003). Childhood Anxiety Disorders. In Mash & Barkley (Eds.). Child Psychopathology: Second Edition. (pp. 279-
329). New York: Guildford Press.
 Costello et al, 2004
Epidemiology (2)
× Girls are more likely than boys to report an anxiety
disorder, esp. specific phobia, panic, agoraphobia, &
separation anxiety disorder
× Children often develop new anxiety disorders over
time (even if the old ones go away)
× Anxiety or depressive disorders in adolescence
predict a 2-3x increase risk of anxiety or depression
in adulthood (Pine et al, 1998) and lower academic
achievement (Woodward & Fergusson, 2001)
× Anxiety in the 1st grade has been shown to predict
anxiety and low academic achievement in reading
and math in the 5th grade (Ialongo et al, 1995)
Epidemiology (3): Non-Referred
× High prevalence of anxiety disorders in non-
referred children:
× 3.5% for Separation Anxiety D/O
× 2.9% for Overanxious D/O
× 2.4% for Simple Phobia
× 1% for Social Phobia (Anderson et al, 1987)
× Bowen (1990) reported 3.6% prevalence of
Separation Anxiety D/O and 2.4% prevalence of
Overanxious D/O in 12 – 16 y/o population
× Lifetime prevalence of panic d/o was 0.6% and
for GAD 3.7% (Whitaker, 1990)
Epidemiology (4)
× A pediatric primary care sample of 7 – 11 y/o
revealed a 1-year prevalence of anxiety d/o of
15.4%; Simple Phobia (9.2%), Separation
Anxiety D/O (4.1%), and Overanxious D/O
(4.6%) were most common (Benjamin 1990)
× A 3 – 4 year f/u study of children/adolescents
with anxiety d/o showed a high remission rate
with 82% no longer meeting criteria for their
initial anxiety d/o (Last et al)
× Separation Anxiety D/O had the highest
recovery rate (96%) and panic the lowest (70%);
during this f/u period, 30% of children developed
new psych d/o and half developed new anxiety
d/o
Risk and Protective Factors
× Behaviorally inhibited young children have
a greater likelihood of anxiety disorders in
middle childhood

× Offspring of parents with anxiety disorders

have a greater risk of anxiety disorder and
high levels of functional impairment

× Insecure attachment relationships with

caregivers (specifically anxious/resistant
attachment) increases the risk of childhood
anxiety disorders
Clinical Course
× The usual course of most anxiety disorders is
chronic with waxing and waning over time
× Individuals sometime “trade” one anxiety
disorder for another over time
× Commonly those with GAD report they’ve felt
anxious their entire life; over half presenting for
treatment report onset in childhood or
adolescence; but onset occurring after 20 is not
uncommon; chronic but fluctuating course
× With Panic D/O, typically attacks become less
severe if they occur more often
× Some anxieties, such as specific phobias, often
dissipate with age, but those that persist into
adulthood remit only infrequently (20%)
Clinical Course (2)
× Social Phobia, on the other hand, most often sets on in
childhood and is commonly lifelong and continuous,
although it may fluctuate in intensity with life stressors
and demands
× Most individuals with OCD show improvement with
time, but about 15% show progressive deterioration and
5% have episodic course; however, an NIMH 2 – 7 year
f/u study found 43% still meeting diagnostic criteria with
only 11% totally asymptomatic
× As with other anxiety disorders, the symptoms of PTSD
often vary over time. Complete recovery occurs within 3
months in about half of cases.
× Separation Anxiety Disorder may develop after a
stressor (e.g., death of a relative or pet, relocation, etc.)
and occur as early as preschool; adolescent onset is rare;
typically it waxes and wanes; although it may be
expressed as Panic Disorder in adults, most children are
free from anxiety disorders as they adults
DSM Diagnoses (1)
× DSM III-R included only 3 childhood anxiety
disorders:
(1) Separation Anxiety Disorder (which
remains); (2) Overanxious Disorder,
which is now
subsumed under GAD; and
(3) Avoidant Disorder, which is now
subsumed under Social Phobia
DSM Diagnoses (2)
× DSM-IV disorders include:
(1) Separation Anxiety Disorders
(2) Panic Disorder
(3) Specific Phobia
(4) Social Phobia (Social Anxiety Disorder)
(5) Obsessive-Compulsive Disorder
(6) Posttraumatic Stress Disorder
(7) Acute Stress Disorder
(8) Generalized Anxiety Disorder
× Others:
× Selective Mutism
× Somatic symptoms
× Trichotillomania
DSM: Separation Anxiety Disorder
× Developmentally inappropriate and
excessive anxiety concerning separation
from home or from those to whom the
individual is attached, as evidenced by 3
or more:
× Excessive distress upon separation from home or
attachment figures occurs or is anticipated
× Excessive worry about losing or harm befalling
attachment figures
× Excessive worry that an event will lead to separation
from an attachment figure (e.g., kidnapping)
× Reluctance to attend school b/c of fear of separation
× Reluctance to be alone or without attachment
figures at home or other locations
× Reluctance to sleep alone or away from home
× Repeated nightmares involving separation
× Repeated complaints of physical symptoms when
separation occurs or is anticipated
× Duration at least 4 weeks
Separation Anxiety Disorder
× Affected children tend to come from closely knit
families
× The kids may exhibit social withdrawal, apathy, and
sadness or difficulty concentrating when separated
× Concerns about death and dying are common
× These children are often viewed as demanding
× Adults with SAD are typically over-concerned about
their children and spouses
× Prevalence estimates about 4% in children and
young adolescents
× More common in 1st degree relatives than general
population
Panic Attacks

× NOT A DISORDER!
× Quite common among adults
Panic Attacks
× Can occur within the context of other mental disorders (e.g.,
Mood D/Os, Substance-Related D/Os, etc.) and some
general medical conditions (e.g., cardiac, respiratory,
vestibular, GI).
× 3 characteristic types of panic: (1) Unexpected (uncued); (2)
situation bound (cued); and (3) situationally predisposed.
× Individuals who seek care will typically describe intense
fear, report that they fear they’re about to die, go crazy,
have an MI/stroke
× Individuals typically report a desire to flee or leave where
they’re at
× With unexpected panic attacks, over time the attacks
typically become situationally bound or predisposed,
although unexpected attacks may occur
× The occurrence of unexpected panic attacks is required for
a dx of Panic D/O; situationally bound or predisposed
attacks are common in Panic D/O but also occur in the
context of other anxiety disorders (e.g., specific and social
phobia, PTSD)
Relationship between PD and other Anxiety Disorders
What does a panic attack look like in a child?
× Children generally report physical symptoms,
rather than psychological symptoms
× May suddenly appear frightened or upset without
explanation
× Often confusing behavior to onlookers
× Children may explain their symptoms as responses
to external triggers
× Young children may not be able to articulate the
intense fears they experience
× Adolescents are generally better at describing what
they experience, especially after the attack has
ended
× *rarer in children
DSM: Panic Disorder
× Both (1) and (2):
× recurrent unexpected Panic Attacks
× at least one of the attacks has been followed by 1 month (or more) of
one (or more) of the following:
× persistent concern about having additional attacks
× worry about the implications of the attack or its consequences (e.g.,
losing control, having a heart attack, “going crazy”)
× a significant change in behavior related to the attacks
× Absence of Agoraphobia
× The Panic Attacks are not due to the direct effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition
(e.g., hyperthyroidism).
× The Panic Attacks are not better accounted for by another mental
disorder, such as Social Phobia (e.g., occurring on exposure to
feared social situations), Specific Phobia (e.g., on exposure to a
specific phobic situation), OCD (e.g., on exposure to dirt in
someone with an obsession about contamination), PTSD (e.g., in
response to stimuli associated with a severe stressor), or
Separation Anxiety D/O (e.g., in response to being away from
home or close relatives).
Panic Disorder
× Patients often are hypersensitive about physical cues and medication side effects
× Reported rates of comorbid MDD are high, ranging from 10-65%; in 2/3 of these
individuals depression co-occurs with panic d/o or follows panic; in the remaining 1/3,
the depression precedes the panic
× Comorbidity with other anxiety disorders is common – social phobia and GAD (15-30%),
specific phobia (2-20%), and OCD (up to 10%). PTSD and Separation Anxiety are also
strongly comorbid, along with hypochondriasis.
× No consistent abnormalities in lab results, but compensated respiratory alkalosis
(decreased bicarb/CO2 with almost normal pH) sometimes noted.
× Lactate and elevated CO2 can be used to induce panic in sufferers
× Correlation with numerous general medical symptoms, including dizziness, arrhythmias,
hyperthyroidism, asthma, COPD, IBS; however, the nature of the association is unclear.
× Debate about whether or not MVP and thyroid disease is more common among sufferers
× Lifetime prevalence in community samples generally 1-2% (but reported as high as 3.5%);
one-year prevalence rates 0.5-1.5%; higher rates in clinic samples (10% in individuals
referred for mental health consultation); 10-30% in general medical clinics and up to
60% in cardiology clinics
× 1/3 to ½ of community samples has comorbid agoraphobia, but the co-occurrence is
much higher in clinical samples
× Age at onset varies, but typically late adolescence/mid-30s; occasionally onset in
childhood; after 45 y/o rare.
× Agoraphobia typically develops within the first year, but can occur at any time
× 1st degree biological relatives are up to 8x more likely to develop Panic D/O; if age of
onset is <20 y/o, 1st degree relatives are up to 20x more likely to develop same.
DSM: Specific Phobia
× Marked and persistent fear that is excessive or unreasonable, cued
by the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood)
× Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response, which may take the form of a
situationally bound or situationally predisposed Panic Attack. In
children, the anxiety may be expressed by crying, tantrums, freezing,
or clinging.
× The person recognizes that the fear is excessive or unreasonable. In
children, this feature may be absent.
× The phobic situation(s) is avoided or else is endured with intense
anxiety or distress.
× Types: Animal Type
× Natural Environment Type (e.g., heights, storms,
water)
× Blood-Injection-Injury Type
× Situational Type (e.g., airplanes, elevators, enclosed
places)
× Other Type (e.g., fear of choking, vomiting, or contracting an illness;
in children, fear of loud sounds or costumed characters)
Specific Phobia
× Rates of co-occurrence with other disorders is 50-80%
× Usually the comorbid condition causes more distress than the specific
phobia; i.e., only 12-30% of affected individuals are estimated to seek
help strictly for a specific phobia
× Vasovagal fainting response is characteristic of Blood-Injection-Injury
Type specific phobias (about 75% of patients report fainting in such
situations)
× Women:men = 2:1
× Although phobias are common in the general population, they rarely
result in sufficient impairment
× Community samples show point prevalence rates of 4-8.8% and lifetime
prevalence rates of 7.2-11.3%; there is decline in the elderly
× First symptoms usually occur in childhood or early adolescence
× Predisposing factors include traumatic events, unexpected Panic
Attacks in the now feared situation, observation of others undergoing
trauma or demonstrating fearfulness, and informational transmission
(e.g., repeated parental warnings, media coverage).
× Feared objects are those which may actually represent some threat or
have represented a threat during some point in human evolution
× Familial aggregation
DSM: Social Phobia
× A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that s/he will act in a
way (or show anxiety symptoms) that will be humiliating or
embarrassing. In children, there must be evidence of the capacity for
age-appropriate social relationships with familiar people and the anxiety
must occur in peer settings, not just in interactions with adults.
× Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or situationally
predisposed Panic Attack. In children, the anxiety may be expressed by
crying, tantrums, freezing, or shrinking from social situations with
unfamiliar people.
× The person recognizes that the fear is excessive or unreasonable. In
children, this feature may be absent.
× The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.
× The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person’s
normal routine, occupational (academic) functioning, or social activities
or relationships, or there is marked distress about having the phobia.
× In individuals under 18 years, the duration is at least 6 months
Social Phobia
× In feared social or performance situations,
individuals with SP experience concerns about
embarrassment and are afraid that others will judge
them to be anxious, weak, “crazy” or stupid.
× Almost always experience physical signs of anxiety
(e.g., palpitations, tremors, sweating, GI, blushing,
etc.)
× Typically there is avoidance of social situations
× Common associated features include
hypersensitivity to criticism or rejection; difficulty
being assertive, low self-esteem and feelings of
inferiority.
× Women>men
× Lifetime prevalence 3-13%
× Occurs more frequently among 1st degree relatives
Obsessive Compulsive Disorder

Insanity is doing the same thing over and over

again and expecting different results.
-Albert Einstein
DSM: Obsessive-Compulsive Disorder
× Either obsessions or compulsions:
× Obsessions as defined by (1), (2), (3), and (4):
*recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive and
inappropriate and that cause marked anxiety or distress
*the thoughts, impulses, or images are not simply excessive worries about
real-life problems
*the person attempts to ignore or suppress such thoughts, impulses, or
images, or to neutralize them with some other thought or action
*the person recognizes that the obsessional thoughts, impulses, or images
are a product of his/her own mind (not imposed from without as in
thought insertion)
× Compulsions as defined by (1) and (2):
*repetitive behaviors (e.g., hand washing, ordering, checking) or mental
acts (e.g., praying, counting, repeating words silently) that the person feels
driven to perform in response to an obsession, or according to rules
that must be applied rigidly
*the behaviors or mental acts are aimed at preventing or reducing
distress or preventing some dreaded event or situation; however,
these behaviors or mental acts either are not connected in a
realistic way with what they are designed to neutralize or prevent
or are clearly excessive
× Affected individual has recognized that the obsessions or compulsions are
excessive or unreasonable. This does not apply to children.
× Time consuming (more than 1 hour/day)
OCD
× Most common obsessions include contamination, repeated
doubts, ordering, aggressive or horrific impulses, and sexual
imagery
× Individuals tend to try and neutralize their obsessive anxiety with
behaviors that ultimately become compulsive
× When individuals try to resist the compulsions, they have a sense
of mounting anxiety that is partially relieved (but perpetuated) by
yielding to the compulsion
× Hypochondriacal concerns are common, with repeated visits to
physicians to seek reassurance
× High concordance with MDD, Eating D/O, and GAD and other
anxiety d/o in adults
× In children, it may be associated with other anxiety d/o, Learning
D/O, Disruptive Behavior D/Os
× Comorbid obsessive-compulsive spectrum disorders
(trichotillomania, body dysmorphic d/o, and habit d/o such as nail
biting) are uncommon but not rare
× There is an established high incidence of OCD in children and
adults with Tourettes (range estimates 35-50%); in reverse, the
numbers are smaller (~8%)
OCD (2)
× Between 20-30% of individuals with OCD report current or
past tics
× Children often do not seek help, and the symptoms may not be
as ego-dystonic as in adults
× In adults the disorder is equally common in males and females;
in childhood onset, the disorder is more common in boys than
girls
× Community studies of children/adolescents estimates lifetime
prevalence at 1-2.3% and one-year prevalence of 0.7%
× Usual onset is late adolescence/early adulthood but may begin
in childhood; males typically have an earlier onset than
females (males, 6-15; females 20-29)
× Higher concordance for mono than dizygotic twins
× Higher risk of OCD amongst 1st degree relatives of patients
with OCD and/or Tourettes
× Pregnancy and childbirth are a strong risk factor for new-
onset OCD
× PANDAS
DSM: Post-Traumatic Stress Disorder
1) Exposed to a traumatic event in which:
× The person experienced, witnessed, or was confronted with
an event or events that involved actual or threatened death
or serious injury, or a threat to the physical integrity of self or
others
× The person’s response involved intense fear, helplessness, or
horror. In children, this may be expressed instead by
disorganized or agitated behavior.
2) The traumatic event is persistently reexperienced in one (or
more) of the following ways:
× Recurrent and intrusive distressing recollections of the event,
including images, thoughts, or perceptions. In young children,
repetitive play may occur in which themes or aspects of the
trauma are expressed.
× Recurrent distressing dreams. In children, there may be
frightening dreams without recognizable content
× Acting or feeling as if the traumatic event were recurring
(includes a sense of reliving the experience, illusions,
hallucinations, and dissociative flashback episodes). In young
children, trauma-specific reenactment may occur
× Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event
DSM: Post-Traumatic Stress D/O (2)
3) Physiological reactivity on exposure to internal or external cues
4) Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the
trauma), as indicated by three (or more) of the following:
× efforts to avoid thoughts, feelings, or conversations associated
with the trauma
× efforts to avoid activities, places, or people that arouse
recollections of the trauma
× inability to recall an important aspect of the trauma
× markedly diminished interest or participation in significant
activities
× feeling of detachment or estrangement from others
× restricted range of affect (e.g., unable to have loving feelings)
× sense of a foreshortened future (e.g., does not expect to have a
career, marriage, children, a normal life span)
Persistent symptoms or increased arousal (not present before the
trauma), as indicated by two (or more) of the following:
× difficulty falling or staying asleep
× irritability or outbursts of anger
× difficulty concentrating
× hypervigilance
× exaggerated startle response
Duration of the disturbance is more than 1 month.
PTSD
Types of Trauma

× Child Maltreatment
× Community violence (witness, victim)
× Natural disasters (fires, hurricanes)
× Motor vehicle collisions
× Disasters (fires, earthquakes)
× War and terrorism
PTSD
Prevalence of Trauma

 Lifetime Prevalence: 1-14%

 Child sexual abuse: studies of 30-40%
 Child physical abuse: 10%
 Witnesses of domestic violence 54%
 Single-incident disaster: 10%
 Motor vehicle collisions:
× Most common form of unintentional injury
in children
PTSD
Prevalence

 Prevalence following war / terrorism

 War
 PTSD diagnosis-Current 18%-37%
 PTSD diagnosis-Lifetime 21%
 Severe PTSD symptoms 31%
PTSD
(In the brain)

Normal Brain: Look at the Hippocampus!

 •Recent research points to the
role of the hippocampus in
PTSD.
PTSD •One job of the hippocampus is
(In the brain) to constantly be generating new
cells to form new memories.
•Patients with PTSD have a
reduction in volume of the
hippocampus because it fails to
regenerate neurons due to the
stress of the traumatic memory.
PTSD
(In the brain)

× War veterans have shown an 8% reduction

in the right hippocampus (no differences in
other parts of the brain).

× Damage to the hippocampus following

exposure to the stress brought on by
childhood abuse leads to distortion and
fragmentation of memories.
PTSD
 Traumatic events experienced prior to
age 11 are 3x more likely to result in
PTSD

 Psychological impact of traumatic events

tends to persist or worsen over time in
children

 Parents tend to underestimate both the

intensity and duration of their children’s
stress reactions
PTSD
 Many trauma victims never develop PTSD
 What predicts who develops PTSD?
 Closer physical proximity
 Closer emotional proximity (death)
 More exposure to media coverage
 Cognitive factors
 Locus of control
 Trauma-specific attributions
PTSD (1)
× Individuals may describe painful guilt feelings about
surviving when others don’t survive, or about the things
they had to do in order to survive
× Recent immigrants from areas of civil unrest may have an
increased prevalence
× Lifetime prevalence approx 8% of adults in US (1 – 14%)
× Symptoms usually begin within the first 3 months of the
trauma experience
× Frequently a person’s reaction to trauma meets criteria
for an Acute Stress D/O in the immediate aftermath
× Severity, duration, and proximity of an individual’s
exposure to the trauma are the most important factors
affecting the likelihood of developing this disorder
× Some evidence of a heritable component
× A h/o of depression in a 1st degree relative is related to an
increased vulnerability
PTSD (2)
× Partial symptomatology is common
× The “fight or flight” response is less adaptive in
young children than adults
× Comorbid conditions are common
× Girls are generally more symptomatic than boys
× Younger children seem to demonstrate more
avoidance symptoms, whereas older children
suffer more reexperiencing and arousal increases
DSM: Acute Stress Disorder
The person has been exposed to a traumatic event in which both of the following were
present:
× The person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical
integrity of self or others
× The person’s response involved intense fear, helplessness, or horror
Either while experiencing or after experiencing the distressing event, the individual has
three (or more) of the following dissociative symptoms:
× A subjective sense of numbing, detachment, or absence of emotional responsiveness
× A reduction in awareness of his/her surroundings (e.g., “being in a daze”)
× Derealization
× Depersonalization
× Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
× The traumatic event is persistently reexperienced in at least one of the following
ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense
of reliving the experience; or distress on exposure to reminders of the traumatic
event.
× Marked avoidance of stimuli that arouse recollections of the trauma (e.g.,
thoughts, feelings, conversations, activities, places, people)
× Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping,
irritability, poor concentration, hypervigilance, exaggerated startle response,
motor restlessness)
× The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and
occurs within 4 weeks of the traumatic event
Acute Stress Disorder
× As a response to a traumatic event, the individual
develops dissociative symptoms
× Individuals may have a decrease in emotional
responsivity; feeling guilty, anhaedonic
× Individuals are at increased risk of developing PTSD
× Rates ranging from 14-33% have been reported for
individuals exposed to severe trauma
× Symptoms are experienced during or immediately
after the trauma, lasting at least 2 days, and
resolving within 4 weeks; if symptoms persist
beyond 1 month, PTSD may be diagnosed if criteria
are met
DSM: Generalized Anxiety Disorder
× Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at least
6 months, about a number of events or activities (such
as work or school performance).
× The person finds it difficult to control the worry.
× The anxiety and worry are associated with three (or
more) of the following six symptoms (with at least
some symptoms present for more days than not for
the past 6 months). Only one item is required in
children.
× restlessness or feeling keyed up or on edge
× being easily fatigued
× difficulty concentrating or mind going blank
× irritability
× muscle tension
× sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep)
GAD
× Many people with GAD experience somatic sx (e.g.,
sweating, nausea, diarrhea) and an exaggerated startle
response
× Autonomic hyperarousal is less common in GAD than
in other anxiety d/o
× Frequently comorbid with Mood D/Os, other Anxiety
D/Os, and Substance-Related D/Os
× In children/adolescents worries often focus on school,
sporting events, punctuality, catastrophic events (e.g.,
earthquakes); children may also be overly conforming,
perfectionistic, and overzealous in seeking approval
× Diagnosed somewhat more in women than men (55-
60%)
× One-year prevalence 3%; lifetime prevalence 5%
× Anxiety as a trait has a familial association
DSM: Selective Mutism
× Consistent failure to speak in specific social
situations (in which there is an expectation
for speaking, e.g., at school) despite
speaking in other situations
× Duration of at least one month with
significant disturbance
Selective Mutism
× Associated features often include shyness, fear
of social embarrassment, social isolation, and
withdrawal, clinging, negativism, temper
tantrums, and oppositional behavior (esp at
home)
× Teasing by peers is common
× Although affected children usually have normal
communication skills, SM is occasionally
associated with a communication disorder
× <1% of kids seen in mental health settings
× Onset is usually before age 5
DSM: Trichotillomania
Recurrent pulling out of hair resulting
in noticeable hair loss
An increasing sense of tension
immediately before pulling out the hair
or when attempting to resist the
behavior
Pleasure, gratification, or relief when
pulling out the hair
Trichotillomania
Sites of hair pulling may include any region of the body
(most common is the head, eyebrows, and eyelashes, but
also axillary, public, perirectal occur)
May occur in episodes scattered throughout the day or in
less frequent but sustained periods lasting for hours
Often occurs during periods of relaxation and distraction
(e.g., watching TV or reading) but may occur during stress as
well
Examining the hair root, twirling it off, pulling the strand
between the teeth, or trichophagia (eating hairs) may occur
and can result in bezoars
Histological examination of affected areas shows damage to
hair follicles and short, broken hairs
No gender differences among children; women>men
Occurrence is unknown; 0.6% lifetime rate among a study of
college students
Affected individuals often deny the hair pulling
People may pull hair from pets, dolls, or clothes
 Assessment of Anxiety in
Children
× There is often low concordance between child
and parent reports of anxiety
× Mothers tend to over-report anxiety symptoms
Rating Scales
× Screen for Child Anxiety Related Emotional
Disorders (SCARED)
× Multidimensional Anxiety Scale for Children
(MASC)
× CYBOCS
× Leyton Inventory
× Achenbach (Child Behavior Checklist)
Treatment of Anxiety Disorders
in Children (Psychotherapy)
× An insecure bond between parent and child
may be an important contributing etiologic
factor; thus treatment aimed at improving
these interactions is crucial
× CBT
× Indications: OCD and phobias (with ERP),
Panic, GAD, SAD
× Two studies support the use of psychodynamic
psychotherapy (Heinicke)
Treatment of Anxiety Disorders
in Children (Medication)

× Four DBPC studies of TCAs for school refusal

show conflicting results
× Case reports support the use of TCAs for
children/adolescents with Panic D/O
× Alprazolam may be useful in children with
overanxious or avoidant disorders
× Benzodiazepines may be useful for adolescents
with Panic D/O
× Alpha-2 agonists and beta-blockers may be
effective for PTSD
Treatment of Anxiety Disorders
in Children (Medication)
× SSRIs have been show to be efficacious in
numerous studies
× Two RDBPC studies of Effexor XR show
somewhat conflicting but generally positive
results (Rynn and Riddle et al)
× Zoloft has the best safety data in children
and adolescents (studies extend two years)
× FDA approval only for OCD:
× Fluoxetine (Prozac®) 7 – 17 y/o
× Sertraline (Zoloft®) 6 – 17 y/o
× Fluvoxamine (Luvox®) 8 – 17 y/o
× Clomipramine (Anafranil®) 11 – 17 y/o
CAMS
× Child and Adolescent Anxiety Multimodal Study
(CAMS), 2008 (Walkup et al, 2008).
× Compared CBT, medications, and combined for
treatment of anxiety disorders
× Randomly assigned 488 children and adolescents with
Separation Anxiety Disorder, Social Phobia, or
Generalized Anxiety Disorder, aged 7 to 17 years, to
one of four treatment groups for 12 weeks.
× CBT for 14 sessions
× Sertraline up to 200 mg/day
× CBT + Sertraline
× Placebo
× Over 80% of children who received combined
treatment improved, as opposed to 60% receiving CBT
only and 55% receiving medication only; although there
was no statistical separation between the CBT and
medication groups
× All treatments were statistically more effective than
placebo, which led to improvement in only 24% of
subjects.
OCD Treatment
× No specific predictors of treatment outcome have been
identified for children; in adults comorbid schizotypy and
tic disorders have been identified as impediments
× CBT with Exposure and Response Prevention (ERP)
× Children who acknowledge that their obsessions are
senseless and their rituals are distressing may be better
candidates for CBT, although lack of insight doesn’t
necessarily render CBT ineffective
× SSRIs and clomipramine (best studied in children);
typically functioning best at higher doses
× A substantial minority will not respond until 8 or 12
weeks of treatment
× In those partially responsive to an SSRI, augmentation
may be useful (only haldol and klonipin have proven
benefit in studies)
OCD Medication Studies

Clomipramine -DeVeaugh-Geiss et al., 1992

Fluoxetine - Riddle et al., 1992
Sertraline - March et al., 1998
Fluvoxamine - Riddle et al., 2001
Fluoxetine - Geller et al., 2001
Paroxetine - Geller et al., 2004
Sertraline in Pediatric OCD

March et al, 1998

DBRPC 12 week multisite trial
N = 187; age = 6-17 years; sertraline 200
mg/d
Sertraline > placebo
Mild side effects
Similar profile of response as clomipramine
Fluvoxamine in
Pediatric OCD
Riddle et al, 2001
DBRPC multisite trial
N = 120; age = 8-17 years; fluvoxamine 50-
200 mg/d
Fluvoxamine > placebo
Mild side effects
Fluoxetine in
Pediatric OCD
Geller et al., 2001
N=103, ages 7-17 years
13 week RDBPC trial
Dose 10-60 mg/day
Decrease CY-BOCS favored fluoxetine (p<.026)
Paroxetine for
Pediatric OCD
Geller et al, 2004
DBPCR 10 week trial
Ages 7-17
N=203
Paroxetine > placebo
Mild side effects
OCD Augmentation
Strategies
Clomipramine
Clonazepam
Antipsychotics
IV Clomipramine
Buspirone
Add second SSRI
Lithium
Stimulants
Others???
Pediatric OCD
Treatment Study
(POTS)
N = 112
Ages 7-17 years
3 sites, 12 weeks
Randomly assigned to CBT, Sertraline,
COMB and placebo
PBO<SER=CBT<COMB
PTSD Treatment
× Debriefing is a popular intervention after
disaster; unfortunately, there is little
evidence documenting its effectiveness
× Treatment involves transforming the child’s
self-concept from victim to survivor
× Projective interventions should include steps
depicting recovery to increase the sense of
mastery
× The literature suggests that desensitization,
relaxation, and other behavioral techniques
are beneficial in treating children with PTSD,
but research is lacking
× Revenge fantasies complicate emotional
resolution
PTSD
× Sertraline Treatment of Children and Adolescents With
Posttraumatic Stress Disorder, RDBPC (Robb et al, 2011)
× 131 children and adolescents (6–17 years old) meeting DSM-IV
criteria for PTSD received 10 weeks of double-blind treatment with
sertraline (50–200mg/day) or placebo; primary efficacy measure
UCLA PTSD-I
× Randomized to sertraline (n=67; female, 59.7%; mean age, 10.8) or
placebo (n=62; female, 61.3%; mean age, 11.2)
× There was no difference between sertraline and placebo in least
squares (LS) mean change in the UCLA PTSD-I score, either on a
completer analysis (−20.4±2.1 vs. −22.8±2.1; p=0.373) or on an last
observation carried forward (LOCF) end point analysis (−17.7±1.9 vs.
−20.8±2.1; p=0.201)
× Attrition was higher on sertraline (29.9%) compared to placebo
(17.7%). D/c due to adverse events was 7.5% with sertraline & 3.2%
with placebo
× Sertraline was a generally safe treatment in children and adolescents
with PTSD, but did not demonstrate efficacy when compared to
placebo during 10 weeks of treatment
PTSD Treatment (2)
× Small open trials have suggested propranolol
and clonidine for persistent arousal
× Zoloft and Paxil FDA approved for adults; small
open trials have suggested the same for SSRIs in
children; gabapentin and antipsychotics
sometimes reportedly useful in adults
× EMDR (Eye Movement Desensitization
Retraining) eye movement therapy shown
effective in adults and one child trial (Chemtob
et al, 2000, adults; Ahmad & Sundelin-Wahlsten,
2008, children)
N-acetylcysteine
× NAC is a metabolite of cysteine, an amino acid; its
metabolite, cystine, reduces synaptic release of glutamate
and enhances glial clearance of glutamate, protecting
against glutamate toxicity
× The restoration of the extracellular glutamate
concentration in the nucleus accumbens seems to block
compulsive behaviors
× Single case report of a patient with SSRI refractory OCD,
who received augmentation of Prozac with NAC led to
marked decrease in Y-BOCS (Lafleur et al, 2006)
× Randomized DBPC study of 45 women and 5 men with
trichotillomania (ages 18 – 65) were assigned to 12 weeks
of NAC up to 2400 mg/d vs. placebo; after 9 weeks of
treatment, 54% of those taking NAC responded to
treatment favorably (Grant et al, 2009)