Anxiety Disorders

Angela Lai
Shelina Hassanali
Christina Majcher

Anxiety Disorders
Most common of all psychiatric disorders affecting children and
youth
Long-term outcomes of anxiety disorders in childhood and
adolescence are still not well understood
Research into childhood anxiety did not begin until the 1980s
Fears and anxieties are a part of normal childhood development,
but for some children this expectation may end up masking the
presence of an existing or emerging anxiety disorder
Less than 20% of children requiring support for any disorder receive
necessary intervention

Types of Anxiety Disorders

Separation Anxiety Disorder (SAD)Panic disordersPosttraumatic Stress DisorderAcute stress disorderAgoraphobia
Generalized anxiety disorder (GAD)Social Anxiety Disorder
Obsessive Compulsive Disorder (OCD)

History of Anxiety Disorders

Childhood anxiety disorders have been referenced for decades.
However, study of pathological anxiety disorders in children began
in the latter part of the 20th century.
Fears and anxiety reactions in children were not acknowledged as a
classification of disease, but were studied and researched to
determine normal developmental reactions and classified according
to etiology.
The delay in attention towards childhood anxiety might have been
the result of disagreements amongst professionals in terms of what
constituted a clinical anxiety state, distinct from fears and anxieties

History of Anxiety Disorders (cont.)

The DSM-III and DSM-III- R provided first attempts to determine
developmentally appropriate diagnostic criteria for phobias and
anxiety disorders in children and adolescents.
In the DSM III, Children could be diagnosed with one of 3 childhood
disorders (Overanxious Disorder, Separation Anxiety Disorder or
Avoidant Disorder) as well as adult anxiety disorders (Phobic
Disorders, Obsessive-Compulsive Disorder, and Posttraumatic
Stress Disorder)
The addition of diagnostic criteria encouraged a large number of
studies examining the epidemiology and clinical characteristics of
phobias and anxiety disorders in children that have influenced the
changes and revisions in criteria for diagnosing anxiety disorders.

Epidemiology of Anxiety Disorders

Epidemiological samples show lower rates of anxiety disorders than
clinical studies show
Of 15 studies, 11 estimate the prevalence of childhood anxiety
disorders at greater than 10% (United States 12-20%)
There has been minimal research focusing on the demographic
composition of anxiety disorders. Consequently, it is very difficult to
come to any firm conclusions concerning racial, socioeconomic, or
gender patterns in childhood and youth anxiety disorders.
The efforts to understand the role of culture in childhood anxiety are
still in the early stages.

Etiological Models of Anxiety Disorders

a)Heritable biological diathesis
b)Generalized psychological vulnerability
c)Specific vulnerability

Albano, Chorpita, and Barlow (Mash & Barkley, Eds., 2003, pp. 307-308) used the model of triplevulnerability to describe the development of anxiety and its disorders as a function of three interacting
dispositions:

Etiological Models: Genetics

Genes contributed to a general risk factor for Anxiety Disorders.
Research findings suggested the followings:

Large-scale twins study: high monozygotic concordance for some

anxiety disorders, but not GAD
Studies of parents with Anxiety Disorders and their children:
anxiety: 7x more likely as control; anxiety 2x more likely than
dysthymic control
First- and Second- degree relatives: children show higher
prevalence of anxiety than relatives of control and relatives of
controls with ADHD
Covariance between anxiety and depression exists and was
accounted by heritable factor

Etiological Models: Temperament

Possibly heritable emotional and behavioural styles that are manifested in
early development of personality
Kagan's "behaviour inhibition model
Behaviour indicators: speech latency and speech frequency Physiology
indicators: heart rate, blood pressure
Kagan's longitudinal research: 15% of children are born predisposed to be
inhibited as infants
o Stability of temperament traits
Biederman's study of behavioural inhibition in high-risk children
Grays model of Behavioural Inhibition System
Big Five Model (Surgency/extraversion, agreeableness,
conscientiousness, emotional stability/neuroticism, and openness)

Psychosocial Factors

Recent research has been focusing on the identification of

possible mechanisms or processes that may establish or
intensify the risk for negative emotions such as coping
strategies, social/familial transmission, information processing,
and complex forms of conditioning

Chorpita (2001) proposed a model that explains the relations of

an individual's sense of control and the development of anxiety

Etiological Models - Parenting

Researchers have identified relevant modeling or conditioning
processes in family interactions that may serve to increase anxious
cognition
Parental modeling, prompting, and rewarding of anxious
behaviours
Family intervention
Cognitive-behavioral therapy + parent anxiety management
Parental rearing style: insufficient affection played a role for Panic
Disorder and GAD; control or overprotection had an impact on
Panic Disorder
Vicarious learning of anxiety: witnessing illness in family member;
parent and anxious children who spend a great deal of time
discussing potential threat of ambiguous situations

Common Comorbidities
Anxiety Disorders are identified as
associated with the features of the
following disorders:
Different types of Anxiety Disorders (SAD
and Panic Disorder)
GAD with OCD
OCD: Tic Disorder, MDD, specific
developmental disorder, simple phobia,
adjustment disorder with depressed mood,
ODD, ADHD
Social Anxiety: Eating Disorders, Autism
Spectrum Disorder, MDD, Dysthymia,
Substance Abuse
(Beidal et al., 2007); Grabhorn, Stenner, Stangier, & Kaufhold
(2006)

Three Anxiety Disorders: Examined In-Depth

Generalized anxiety disorder (GAD)Obsessive Compulsive

Disorder (OCD)Social anxiety disorder

Generalized
Anxiety Disorder
Excessive, uncontrollable
and often irrational worry
about everyday things that
is disproportionate to the
actual source of worry,
occurring more days than
not, for at least 6 months
To diagnose GAD in
children, there must also
be the presence of at least
one physiological
symptom.

GAD Core Symptoms

Most frequent worries include tests/grades, natural disasters,

being physically attacked, future school performance, and social
relationships

Often worry about adult concerns, like family finances

Often described as placing high standards on themselves, self

conscious and require frequent reassurance from others

It is not the number of worries, but rather the intensity of the

worries that separates children with GAD from non-referred
children

Children with GAD are often described as little worriers

GAD Related Symptoms

Younger children (ages 5-11) tend to present with comorbid
separation anxiety and ADHD
Older children (ages 12-19) comorbid with major depression and
simple (specific) phobia
Physical complaints are often associated, particularly headaches,
stomach aches, muscle tension, sweating and trembling
Adolescents (especially girls) with GAD also have a high
frequency of disturbing dreams

DSM-IV-TR Diagnostic Criteria

A. 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).
B. The person finds it difficult to control the worry.
C. 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). Note: Only one item is required in children.
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless sleep)

GAD Diagnostic Criteria (cont.)

D. The focus of the anxiety and worry is not confined to features of an Axis I
disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic
Disorder), being embarrassed in public (as in Social Phobia), being contaminated
(as in ObsessiveCompulsive Disorder), being away from home or close
relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia
Nervosa), having multiple physical complaints (as in Somatization Disorder), or
having a serious illness (as in Hypochondriasis), and the anxiety and worry do
not occur exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
F. The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition
(e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a
Psychotic Disorder, or a Pervasive Developmental Disorder.

GAD in the DSM V

A. Excessive anxiety and worry (apprehensive expectation) about two (or more)
domains of activities or events (e.g., family, health, finances, and school/work
difficulties).
B. The excessive anxiety and worry occurs on more days than not, for 3 months or more
C. The anxiety and worry are associated with one or more of the following
symptoms:
1. restlessness or feeling keyed up or on edge
2. muscle tension
D. The anxiety and worry are associated with one or more of the the following
behaviours:
1. marked avoidance of activities or events with possible negative outcomes
2. marked time and effort preparing for activities or events with possible negative
outcomes
3. marked procrastination in behaviour or decision making due to worries
4. repeatedly seeking reassurance due to worries

GAD in School Settings

Jacob's story.
http://youtu.be/4RSdV9R8wXQ
Children often display the following:
Physical complaints

High rate of school absence

Tendency toward perfectionism

Irritable

Test anxiety

Fixate on worries

Internalizing/externalizing behaviours

Low coping skills

Social challenges

Difficulty concentrating

Can affect academic performance

Parents are often the ones to indicate to the school the intensity of
their child's worries

GAD Treatment and Interventions

Cognitive Behaviour Therapy
FRIENDS program- School-based anxiety prevention and resiliency
skill-building program, sponsored by the the Ministry of Children
and Family Development in British Columbia.

Obsessive
Compulsive
Disorder (OCD)
marked distress for
an individual and/or
significant
impairment in
functioning.
Recurrent and intrusive
obsessions and compulsions
that are time-consuming, or
which cause

OCD Core Symptoms

Characterized by obsessions (cause anxiety) and/or

compulsions (neutralize anxiety)

What is the difference between obsessions and compulsions?

http://www.youtube.com/watch?v=_wEU-165NRY
(from 2:24)
Important to note that non-anxious children may also have
ritual-like behaviours that are not OCD (arranging toys,
night-time routines)
Distinguishing factor is that children with OCD will show
distress if ritual is altered

OCD Related Symptoms

Other anxiety disorders and depression (most common)
Early onset OCD is associated with higher severity of
depressive symptoms, increased risk for ADHD, GAD and
Specific Phobia

Eating disorders and personality disorders

In children, OCD may also be associated with LD and
Behaviour Disorders

Mood disorders may be more prevalent in adolescents with

OCD

High incidence of OCD in children and adults with Tourettes

DSM-IV-TR Diagnostic Criteria

A. Either obsessions or compulsions:

Obsessions are defined as:

(1) 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
(2) the thoughts, impulses, or images are not simply excessive worries about reallife problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images,
or to neutralize them with some other thought or action
(4) the person recognizes that the obsessional thoughts, impulses, or images are a
product of his or her own mind (not imposed from without as in thought insertion)

DSM-IV-TR Diagnostic Criteria (cont.)

Compulsions as defined as:
(1) 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
(2) 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

DSM-IV-TR Diagnostic Criteria (cont.)

B. At some point during the course of the disorder, the person has realized that the
obsessions or compulsions are
excessive or unreasonable. Note: This does not apply to children (limited cognitive
awareness)
C. The obsessions or compulsions cause marked distress, are time consuming
(take more than 1 hour a day), or significantly interfere with the persons normal
routine, occupational (or academic) functioning, or usual social
activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it.
E. The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.

DSM-IV-TR Diagnostic Criteria (cont.)

Specify if:
With Poor Insight: if, for most of the time during the current episode, the person
does not recognize that the obsessions and compulsions are excessive or
unreasonable

OCD in the School Setting

Could cause social isolation (i.e. difficulty sharing items, playing

games, group work, sleepovers, etc)

School work and homework may be affected (i.e. checking,

erasing, doubting, impaired concentration, etc)

Adolescents may find increased independence anxietyprovoking (i.e. dating, working, driving)
Attendance may be impacted

OCD Treatment and Interventions

Cognitive Behavioral Therapy (CBT)
o Cognitive Restructuring (changing thought patterns)
o Exposure & Response Prevention (ERP) (i.e. "exposure
therapy"/desensitization)
o Mindfulness (learning to be aware of and accept
uncomfortable psychological experiences)
Medicines
o SSRI's (to help balance chemicals in the brain)
o Sometimes used to make CBT more effective
o Can have side effects, need to be careful with children
(OCD Center of Los Angeles)

OCD Treatment and Interventions

Children's books:

By Holly L. Niner

By A.P. Wagner & P.A. Jutton

Social Anxiety
Disorder
(Social Phobia)
A marked and
persistent fear of
one or more social
or performance
situations in which
the person fears that
embarrassment may
occur.

Core Symptoms
Immediate anxiety responses or panic attack upon exposure of
the situation

Avoidance or extreme distress

Excessive concerns about embarrassment, negative evaluation,
and rejection; processing social situations negatively

Reports of autonomic symptoms and sensations

o

Younger children: illnesses, crying

Youth: fears of blushing, avoid others

Prevalence and Related Symptoms

Most often diagnosed in adolescence years but does occur

earlier in childhood
o .5% in children and 2% and 4% in adolescents
o higher rates of Social anxiety disorders in females than
males (as cited in Chavira & Stein 2005)
Vulnerability
Increased self-consciousness
Increased demands due to changes in middle school
environment
Children: lower perceptions of cognitive competence, higher
trait of anxiety
Youth: later anxiety, major depressive disorders, substance
abuse disorder, suicide attempts, educational
underachievement

Subtypes
Generalized subtype is the most common form of Social Anxiety
Disorder in children and adolescents (Hofmann, Moscovitch,
Kim, & Taylor, 2004)
Generalized subtype appears to be a more pervasive and
disabling condition than non-generalized subtypes (Chavira &
Stein 2005)

DSM-IV-TR Diagnostic Criteria

A. 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; with the fears that he/she will act in a way that
will be humiliating or embarrassing.
B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or situationally
predisposed Panic Attack.
C. The person recognizes that the fear is excessive or unreasonable.**
Children and adolescents may fail to recognize their fears as unreasonable and
excessive (attributed to cognitive-developmental limitations), this insight is
required in adults to make the diagnosis.

D. The feared social or performance situations are avoided or else are

endured with intense anxiety or distress.

Diagnostic Criteria cont'd

E. 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.
F. In individuals under age 18 years,the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted for by another mental disorder.
H. If a general medical condition or another mental disorder is present, the
fear in Criterion A is unrelated to it.

DSM V
A. Marked fear of anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
E.g., social interactions: having a conversation, being observed:
eating or drinking, or performing in front of others: giving a speech.
B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated (e.g., be
humiliated, embarrassed, or rejected) or will offend others.
C. Is the same as "B" in DSM-IV-TR.
D. Remains the same.
E. The fear or anxiety is out of proportion to the actual threat posed
by the social situation.

DSM V
F. Remains the same.
G. The same as "E" in DSM-IV-TR (impairment in functions).
H. The same as "G" in DSM-IV-TR (not due to substance induced).
I. The disturbance is not better accounted for by another mental
disorder.
J. If another medical condition (e.g., stuttering, Parkinson's disease,
obesity, disfigurement from burns or injury is present, the fear,
anxiety, or avoidance is unrelated or is out of proportion to it).
Specify if: performance only; selective mutism.

Video Clip: Social Anxiety Disorder

Rob's story.
http://youtu.be/LFM8M33k2UI

Social Anxiety in School Settings/Home

Peer relationships

Friends
Reluctant to join
group activities
Loneliness
Shy, quiet
Peer victimization
(Siegel, La Greca,
Harrison 2009)

School

Reading aloud
Request for assistance
Unstructured peer
encounters
Gym activities
Working in groups
Test taking
Eating in the Cafeteria

Home
Avoidance

of
extended family
gatherings, answering
the phone or doorbell
Refuse to order for
themselves in
restaurants
Lag behind peers in
meeting
developmental
challenges

Social Anxiety Disorder Treatment and

Interventions

Pharmacotherapeutic intervention (Chavira & Stein, 2005)

Selective Serotonin Reuptake Inhibitor (SSRI) - concerns of possible
increased suicidal thinking, suicide attempts, or self-harms

Cognitive behavioural therapy and Behavioural therapy (Chavira &

Stein, 2005)
Efficacy of these types of therapy are supported
Gains are maintained post intervention
Symptom reduction

Current Issues and Future Directions

with Anxiety Disorders
Hudson and Dodd, 2012
Examined how various factors (child anxiety, behavioural inhibition (BI),
maternal over-involvement, maternal negativity, mother-child attachment and
maternal anxiety), as assessed at age four, predict anxiety at age nine.
Child anxiety, BI, maternal anxiety, and maternal over-involvement were
significant predictors of clinical anxiety
These results can inform intervention:
Important to consider BI in young children; maybe they're not just
shy!
Early intervention is important, even in preschool (growing out of
it is not the case for all children)

Involve mothers; decrease mothers anxiety and include

parenting modules (i.e. overprotection)

Current Issues and Future Directions

with Anxiety Disorders
Walkup et al., 2008
Examined 488 children between age 7-17 with varying anxiety diagnoses.
Over a 12 week period - either received CBT, Sertraline (AKA Zoloft- SSRI),
combination of CBT and Sertraline, or placebo
Results: combination had best outcome, followed by CBT alone, then
Sertraline alone, and least effective was placebo
These results can inform intervention:

Shows that combination therapy offers best chances for positive outcomes
If we have to choose one, CBT had better outcomes
Can help to inform reluctant parents about meds

Current Issues and Future Directions

with Anxiety Disorders
FearShrinker - $5.99 (iPad)
o

Fear scale, anxiety symptoms, strategies (i.e. muscle relaxation)

Magical Adventures - $2.99 (iPad)

o

Meditations for kids

iCounsellor - $0.99 (iPhone, iPad, iTouch)

o

Rating scale, calming activities, changing thoughts, triggers, strategies

Various apps, blogs, websites, forums, e-books

Relaxing music on iPod, etc.

Class Survey:
Diagnosing
Cartoon
Characters

Diagnosing Cartoon Characters: Survey

Results!

What diagnosis would you give to Piglet (Winnie the Pooh)?

58%
Generalized
Anxiety
Disorder

Diagnosing Cartoon Characters: Survey

Results!

47% OCD
What diagnosis would you give to Gurgle (Finding Nemo)?

32%
Specific
Phobia

Diagnosing Cartoon Characters: Survey

Results!

What diagnosis would you give to Charlie Brown ?

37% Social
Phoba
32% GAD

Diagnosing Cartoon Characters: Survey

Results!

53% OCD
What diagnosis would you give to Rabbit (Winnie the Pooh)?

Diagnosing Cartoon Characters: Survey

Results!

What diagnosis would you give to Marlin (Finding Nemo)?

58%
Separation
Anxiety
Disorder

Diagnosing Cartoon Characters: Survey

Results!

37% GAD
What diagnosis would you give to Daffy Duck?

26% OCD

Diagnosing Cartoon Characters: Survey

Results!

53% GAD
What diagnosis would you give to Lion (Wizard of Oz)?

32% Social
Phobia

Diagnosing Cartoon Characters: Survey

Results!
It may be difficult to diagnose if the individual exhibits symptoms of multiple
anxiety disorders

Consultation & collaboration are very important in the field of psychology -

different professional backgrounds, experiences and insights are beneficial for

appropriate diagnoses and subsequent treatment

The moral of the story is....

References
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood Anxiety Disorders. In
Barkley, R. A. & Mash, E. J. Editor (Ed.)., Child psychopathology, 2nd edition, pp. 279329. New York: Guilford Press.
American Psychiatric Association (2007). Diagnostic and Statistical Manual of Mental
Disorders: Fourth Edition: Text Revision. Washington, DC.
American Psychiatric Association, The future of psychiatric diagnosis. (2012). DSM-V
Development. Retrieved from http://www.dsm5.org/Pages/Default.aspx
Andrews G, Hobbs MJ, Borkovec TD, Beesdo K, Craske MG, Heimberg RG, Rapee
RM, Ruscio AM, Stanley MA. Generalized Worry Disorder: A review of DSM-IV
Generalized Anxiety Disorder and Options for DSM-V. Depression & Anxiety, 2010;
27:134-147.
AnxietyBC (2012, June 26). Jacob monologue. Retrieved October 12, 2012 from
http://youtube.com/4RSdV9R8wXQ

References
AnxietyBC (2012, June 26). Christine monologue. Retrieved October 12, 2012 from
http://www.youtube.com/watch?v=dgbQ5tnTxto&feature=share&list=ULdgbQ5tnTxt
AnxietyBC (2012, June 26). Rob monologue. Retrieved October 12, 2012 from
http://www.youtube.com/watch?v=LFM8M33k2UI&feature=share&list=ULLFM8M33k2UI

Beidel, B. C., Turner, S. M., Young, B. J., Ammerman, R. T., Sallee, F. R., & Crosby, L.
(2007). Psychopathology of adolescent social phobia. Journal of Psychopathological
Behavioural Assessment 29:47-54. DOI: 10.1007/s10862-006-9021-1
Chavira, D. A.,& Stein, M. B. (2005). Childhood Social Anxiety Disorder: From
Understanding to Treatment. Children and Adolescent psychiatric clinical (14): 797-818.
Kickthefaucet (2010, April 25). Dr. Oz: What is OCD? Retrieved October 15, 2012 from
http://www.youtube.com/watch?v=_wEU-165NRY
Friends in Canada (n.d.) Friends for life: Preventing and treating anxiety in children.
Retrieved from http://www.friendsinfo.net/ca.htm

References
Grabhorn, R., Stenner, H., Stangier, U., & Kaufhold, J. (2006). Social Anxiety in
Anorexia and Bulimia Nervosa: The mediating role of shame. Clinical psychology and
psychotherapy 13:12-19. DOI: 10.1002/ccp.463
Hofmann, S. G., Moscovitch D. A., Kim, H. J., & Taylor, A. N. (2004), Changes in SelfPerception during treatment of social phobia. Journal of Consulting and Clinical
Psychology: 72: 588-596
Hudson, J.L. & Dodd, H.F. (2012). Informing Early Intervention: Preschool Predictors of
Anxiety Disorders in Middle Childhood. PLoS ONE 7(8): 1-7.
Maclean, K. L., (2004). Peaceful piggy meditation. Morton Grove, III: Albert Whitman &
Co.
OCD Center of Los Angeles (2012). http://www.ocdla.com/index.html
Siegel, R., S., Greca, A. M. L., & Harrison, H. M. (2009). Peer Victimization and social
anxiety in adolescents: prospective and reciprocal relationship. Journal of Youth
Adolescence (38):1096-1109.

References
Steffloverrsyou82 (2010, Dec 13). Scaredy Squirrel Read Aloud. Retreived
October 12, 2012 from http://youtu.be/DasoZb0cvdE.
Walkup, J.T., Albano, A.M., Piacentini, J., Birmaher,B., Comton, S.N., Sherrill J.T.,
Ginsburg, G.S., Rynn, M.A., McCracken, J., Waslick, B., Iyengar, S., March, J.S., &
Kendall, P.C. (2008). Cognitive Behavioral Therapy, Sertraline, or a Combination in
Childhood Anxiety. The New England Journal of Medicine, 359(26): 2753-2766.