Abnormal Child Psychology Sixth Edition 11 Anxiety and

Abnormal Child Psychology Sixth Edition 11 Anxiety and Obsessive—Compulsive Disorders Eric J. Mash A. Wolfe ©David Cengage Learning 2016 © Cengage Learning 2016

Description of Anxiety Disorders • Anxiety: a mood state characterized by strong negative emotion and bodily symptoms of tension in anticipation of future danger or misfortune • Anxiety disorders involve experiencing excessive and debilitating anxieties; occur in many forms • Many children with anxiety disorders suffer from more than one type © Cengage Learning 2016

Experiencing Anxiety • Moderate amounts of anxiety helps us think and act more effectively • Excessive, uncontrollable anxiety can be debilitating • The neurotic paradox is a self-defeating behavior pattern – fear with no threat • Fight/flight response – Immediate reaction to perceived danger or threat aimed at escaping potential harm © Cengage Learning 2016

Three Interrelated Anxiety Response Systems • Physical system – The brain sends messages to the sympathetic nervous system, fight/flight response • Cognitive system – Activation leads to feelings of apprehension, nervousness, difficulty concentrating, and panic • Behavioral system – Aggression is coupled with a desire to escape threatening situation © Cengage Learning 2016

The Many Symptoms of Anxiety © Cengage Learning 2016

Anxiety Versus Fear and Panic • Anxiety - future-oriented mood state – May occur in absence of realistic danger • Fear - present-oriented emotional reaction – Occurs in the face of a current danger and marked by a strong escape tendency • Panic – A group of physical symptoms of fight/flight response - unexpectedly occur in the absence of obvious danger or threat © Cengage Learning 2016

Normal Fears, Anxieties, Worries, and Rituals • Moderate fear and anxiety are adaptive – Emotions and rituals that increase feelings of control are common in children and teens • Normal fears – Fears that are normal at one age can be debilitating a few years later – A fear defined as normal depends on its effect on the child and how long it lasts – The number and types of fears change over time © Cengage Learning 2016

Common Fears and Anxieties © Cengage Learning 2016

Common Fears and Anxieties (cont’d. ) © Cengage Learning 2016

Normal Anxieties • Anxieties are common during childhood and adolescence – Common examples • Separation anxiety • Test anxiety • Excessive concern about competence • Excessive need for reassurance • Anxiety about harm to a parent © Cengage Learning 2016

Normal Anxieties (cont’d. ) • Girls display more anxiety than boys, but symptoms are similar • Some specific anxieties decrease with age • Nervous and anxious symptoms may remain stable over time © Cengage Learning 2016

Normal Worries • Children of all ages worry • Worry serves a function in normal development – Moderate worry can help children prepare for the future • Children with anxiety disorders do not necessarily worry more – They worry more intensely than other children © Cengage Learning 2016

Normal Rituals and Repetitive Behavior • Normal routines help children gain control and mastery of their environment • Many common childhood routines involve repetitive behaviors and doing things “just right” – Neuropsychological mechanisms underlying compulsive, ritualistic behavior in normal development and those in OCD may be similar © Cengage Learning 2016

Seven Categories of Anxiety Disorders • • Separation Anxiety Disorder (SAD) Generalized anxiety disorder (GAD) Specific phobia Social anxiety disorder Panic disorder (PD) Agoraphobia Selective mutism © Cengage Learning 2016

Separation Anxiety Disorder (SAD) • Separation anxiety is important for a young child’s survival – It is normal from about age 7 months through preschool years – Lack of separation anxiety at this age may suggest insecure attachment • SAD is distinguished by: – Age-inappropriate, excessive, and disabling anxiety about being apart from parents or away from home © Cengage Learning 2016

Diagnostic Criteria for Separation Anxiety Disorder © Cengage Learning 2016

Prevalence and Comorbidity • SAD is one of the two most common childhood anxiety disorders • Occurs in 4 -10% of children – It is more prevalent in girls than in boys • More than 2/3 of children with SAD have another anxiety disorder and about half develop a depressive disorder © Cengage Learning 2016

Onset, Course, and Outcome • SAD has the earliest reported age of onset of anxiety disorders (7 -8 years of age) and the youngest age at referral • Progresses from mild to severe • Associated with major stress – Examples: moving to new neighborhood or entering a new school • SAD persists into adulthood for more than 1/3 of affected children and adolescents © Cengage Learning 2016

Outcome as Adults • As adults, more likely to experience: – Relationship difficulties – Other anxiety disorders and mental health problems – Functional impairment in social and personal life © Cengage Learning 2016

School Reluctance and Refusal • School refusal behavior – Refusal to attend classes or difficulty remaining in school for an entire day • Occurs most often in ages 5 -11 • Fear of school may be fear of leaving parents (separation anxiety), but can occur for many other reasons • Serious long-term consequences result if it remains untreated © Cengage Learning 2016

Specific Phobia • Age-inappropriate persistent, irrational, or exaggerated fear that leads to avoidance of the feared object or event and causes impairment in normal routine – Lasts at least 6 months – Extreme and disabling fear of objects or situations that in reality pose little or no danger or threat – Child goes to great lengths to avoid the object/situation © Cengage Learning 2016

Diagnostic Criteria for Specific Phobia © Cengage Learning 2016

Specific Phobia (cont’d. ) • Prevalence and comorbidity – About 20% of children are affected at some point in their lives, although few are referred for treatment – More common in girls • Onset, course, and outcome – Onset at 7 -9 years - phobias involving animals, darkness, insects, blood, and injury – Clinical phobias are more likely than normal fears to persist over time © Cengage Learning 2016

Social Anxiety Disorder (Social Phobia) • A marked, persistent fear of social or performance requirements that expose the child to scrutiny and possible embarrassment – Anxiety over mundane activities – Most common fear is doing something in front of others – More likely than other children to be highly emotional, socially fearful; and inhibited, sad, and lonely © Cengage Learning 2016

Diagnostic Criteria for Social Phobia © Cengage Learning 2016

Prevalence, Comorbidity, and Course • Lifetime prevalence of 6 -12% of children • Twice as common in girls • Two-thirds also have another anxiety disorder • 20% also suffer from major depression and may self-medicate with alcohol and other drugs • Most common age of onset is early to midadolescence, and is rare under age 10 © Cengage Learning 2016

Prevalence, Comorbidity, and Course (cont’d. ) © Cengage Learning 2016

Selective Mutism • Failure to talk in specific social situations, even though they may speak loudly and frequently at home or other settings • Estimated to occur in 0. 7% of children • Average of onset is 3 -4 years • May be an extreme type of social phobia, but there are differences between the two disorders © Cengage Learning 2016

Panic • Panic attacks – Characteristics: sudden, overwhelming period of intense fear or discomfort accompanied by four or more physical and cognitive symptoms characteristic of the fight/flight response – Are rare in young children; common in adolescents • Young children may lack cognitive ability to make catastrophic misinterpretations – Are related to pubertal development © Cengage Learning 2016

Panic Disorder • In severe cases, high anticipatory anxiety and situation avoidance may lead to agoraphobia – Fear of being alone in and avoiding certain places or situations – Fear of having a panic attack in situations where escape would be difficult or help is unavailable – Does not usually develop until age 18 or older © Cengage Learning 2016

Diagnostic Criteria for Panic Disorder © Cengage Learning 2016

Prevalence and Comorbidity • Panic attacks are common (16% of teens) • Panic disorder is less common (about 2. 5% of teens 13 -17 years) • Panic attacks are more common in adolescent females than adolescent males • Comorbidity adolescents with PD – Most commonly have another anxiety disorder or depression • At risk for suicidal behavior; alcohol or drug abuse © Cengage Learning 2016

Onset, Course, and Outcome • Onset, course, and outcome – Age of onset for first panic attack 15 -19 years; 95% of PD adolescents are post-pubertal – Lowest remission rate for any of the anxiety disorders © Cengage Learning 2016

Generalized Anxiety Disorder • Generalized anxiety disorder (GAD) – Excessive, uncontrollable anxiety and worry – Worrying can be episodic or almost continuous – Worry excessively about minor everyday occurrences • Accompanied by at least one somatic symptom, such as: – Headaches, stomach aches, muscle tension, and trembling © Cengage Learning 2016

Diagnostic Criteria for Generalized Anxiety Disorder © Cengage Learning 2016

Generalized Anxiety Disorder (cont’d. ) • Prevalence and comorbidity – Nat’l survey: lifetime prevalence rate - 2. 2% – Equally common in boys and girls – Accompanied by high rates of other anxiety disorders and depression • Onset, course, and outcome – Average of onset is early adolescence – Older children have more symptoms – Symptoms persist over time © Cengage Learning 2016

Obsessive-Compulsive Disorder • An unusual disorder of ritual and doubt – Characterized by recurrent, time-consuming and disturbing obsessions and compulsions • Obsessions: persistent and intrusive thoughts, urges, or images - experienced as intrusive and unwanted • Compulsions: repetitive, purposeful, and intentional behaviors or mental acts performed to relieve anxiety © Cengage Learning 2016

Obsessive-Compulsive Disorder (cont’d. ) • OCD is extremely resistant to reason • OCD children often involve family members in rituals • Normal activities of children with OCD are reduced, and health, social and family relations, and school functioning can be severely disrupted © Cengage Learning 2016

Diagnostic Criteria for Obsessive. Compulsive Disorder © Cengage Learning 2016

Prevalence and Comorbidity • Prevalence and comorbidity – Lifetime prevalence in children and adolescents is 1 -2. 5% – Clinic-based studies find it twice as common in boys – Comorbidities most common are other anxiety disorders, depressive disorders, disruptive behavior disorders • Substance-use; learning and eating disorders; vocal and motor tics are also overrepresented © Cengage Learning 2016

Onset, Course, and Outcome • Onset, course, and outcome – Average of onset 9 -12 years with peaks in early childhood and early adolescence – Chronic disorder - as many as two-thirds continue to have OCD 2 -14 years after initial diagnosis © Cengage Learning 2016

Associated Characteristics • Children with anxiety disorders display a number of associated characteristics – Cognitive disturbances – Physical symptoms – Social and emotional deficits – Anxiety and depression © Cengage Learning 2016

Cognitive Disturbances • Disturbance in how information is perceived and processed • Intelligence and academic achievement – Despite normal intelligence, deficits are seen in memory, attention, and speech or language – High levels of anxiety can interfere with academic performance – Those with generalized social anxiety may drop out of school prematurely © Cengage Learning 2016

Cognitive Disturbances (cont’d. ) • Threat-related attentional biases – Selective attention is given to potentially threatening information – Anxious vigilance or hypervigilance permits the child to avoid potentially threatening events © Cengage Learning 2016

Cognitive Disturbances (cont’d. ) • Cognitive errors and biases – Perceptions of threats activate dangerconfirming thoughts – Children with conduct problems select aggressive solutions in response to a perceived threat – Children with anxiety disorders see themselves as having less control over anxiety-related events than other children © Cengage Learning 2016

Physical Symptoms • Somatic complaints, such as stomachaches or headaches, are more common in children with GAD, PD and SAD than in those with a specific phobia • 90% with anxiety disorders have sleeprelated problems, e. g. , nocturnal panic • High rates of anxiety in adolescence are related to reduced accidents and accidental deaths in early adulthood © Cengage Learning 2016

Social and Emotional Deficits • Anxious children – Display low social performance and high social anxiety – See themselves as shy and socially withdrawn, and report low self-esteem, loneliness, and difficulty initiating and maintaining friendships – Have deficits in understanding emotion and in differentiating between thoughts and feelings © Cengage Learning 2016

Anxiety and Depression • A child’s risk for accompanying disorders will vary with the type of anxiety disorder – Depression is diagnosed more often in children with multiple anxiety disorders – Negative affectivity: persistent negative mood, – Positive affectivity: persistent positive mood • Negatively correlated with depression, but is independent of anxiety symptoms and diagnoses © Cengage Learning 2016

Anxiety and Depression (cont’d. ) • Physiological hyperarousal (somatic tension, shortness of breath, dizziness, etc. ) may be unique to anxious children • Predictors and environmental influences are different © Cengage Learning 2016

Gender, Ethnicity, and Culture • Higher incidence of anxiety disorders in girls suggests genetic influences and related neurobiological differences • The experience of anxiety is pervasive across cultures • Ethnicity and culture may affect the expression, developmental course, and interpretation of anxiety symptoms © Cengage Learning 2016

Cumulative Incidence of Anxiety Disorders in Females and Males © Cengage Learning 2016

Theories and Causes – Early Theories • Classical psychoanalytic theory – Anxieties and phobias seen as defenses against unconscious conflicts rooted in the child’s early upbringing • Behavioral and learning theories – Fears and anxieties learned through classical conditioning and maintained through operant conditioning (two-factor theory) © Cengage Learning 2016

Early Theories (cont'd. ) • Bowlby’s theory of attachment – Fearfulness is biologically rooted in the emotional attachment needed for survival – Early insecure attachments lead children to view the environment as undependable, unavailable, hostile, and threatening • Leading to development of anxiety and avoidance behaviors • No single theory is sufficient © Cengage Learning 2016

Temperament • Variations in behavioral reactions to novelty result in part from inherited differences in the neurochemistry of brain structures – Amygdala - primary function is to react to unfamiliar or unexpected events – Projections of amygdala to the motor system, anterior cingulate and frontal cortex, hypothalamus, and sympathetic nervous system © Cengage Learning 2016

Temperament (cont'd. ) • Behavioral inhibition (BI): a low threshold for novel and unexpected stimuli – Place an individual at greater risk for anxiety disorders • Development of anxiety disorders in BI children depends on: – Gender, exposure to early maternal stress, and parental response © Cengage Learning 2016

Family and Genetic Risk • Family and twin studies suggest – About 1/3 of the variance in childhood anxiety symptoms is genetic – Serotonin and dopamine systems are related to anxiety – Genes are linked to broad anxiety-related traits (e. g. , behavioral inhibition) • No strong direct link between specific genetic markers and specific types of anxiety disorders © Cengage Learning 2016

Neurobiological Factors • The entire anxiety response system is controlled by several interrelated to produce anxiety – Hypothalamic-pituitary-adrenal (HPA) axis – Limbic system – Ventrolateral prefrontal cortex – Other cortical and subcortical structures – Primitive brain stem © Cengage Learning 2016

Neurobiological Factors (cont'd. ) • An overactive behavioral inhibition system (BIS) implicated – BIS may be shaped by early life stressors • Brain abnormalities have been implicated in children who are anxious and/or behaviorally inhibited • Primary neurotransmitter system implicated in anxiety disorders – γ-aminobutyric acidergic (GABA-ergic) system © Cengage Learning 2016

Family Factors • Parenting practices – Parents of anxious children are seen as overinvolved, intrusive, or limiting child’s independence • Prolonged exposure to high doses of family dysfunction associated with extreme trajectories of anxious behavior • Low SES • Insecure early attachments © Cengage Learning 2016

A Possible Developmental Pathway For Anxiety Disorders © Cengage Learning 2016

Treatment and Prevention • Overview – Main line of attack for treating anxiety disorders is exposing children to anxiety producing situations, objects, and occasions • Treatments are directed at modifying: – Distorted information processing – Physiological reactions to perceived threat – Sense of a lack of control – Excessive escape and avoidance behaviors © Cengage Learning 2016

Behavior Therapy • Main technique is exposure to feared stimulus – While providing children with ways of coping other than escape and avoidance • Systematic desensitization • Flooding: prolonged repeated exposure • Response prevention prevents child from engaging in escaping or avoidance stimuli • Modeling and reinforced practice © Cengage Learning 2016

Cognitive-Behavior Therapy (CBT) • The most effective procedure for treating most anxiety disorders • Almost always used with exposure-based treatments • Coping Cat • Skills training and exposure combat problematic thinking • Computer-based CBT has also been shown to be effective © Cengage Learning 2016

Family Interventions • Child-focused treatments may have spillover effects into the family • Addressing children’s anxiety disorders in a family context may result in more dramatic and lasting effects • Family treatment for OCD: – Provides education about the disorder – Helps families cope with their feelings © Cengage Learning 2016

Medications • Medications can reduce symptoms, especially for OCD – The most common and effective medications are selective serotonin reuptake inhibitors (SSRIs), especially for OCD – Medications are most effective when combined with CBT • CBT is the first line of treatment © Cengage Learning 2016

Prevention • Prevention study – Researchers identified children with a mean age of less than 4 years who were at-risk for later anxiety disorders • Brief intervention (six 90 -min group sessions) was carried out – Intervention group (compared with a control group) showed fewer anxiety disorders and lower symptoms severity • Untreated children may be on a worsening developmental trajectory © Cengage Learning 2016

Prevention (cont’d. ) © Cengage Learning 2016