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The Society for Clinical Child and Adolescent Psychology (SCCAP): Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent Mental Health Problems With additional support from Florida International University and The Children’s Trust. Workshop Evidence-based Treatment for Child Anxiety Problems: Cognitive Behavioral Strategies Wendy Silverman, Ph.D. Professor of Psychology and Director of Clinical Training Director, Child Anxiety and Phobia Program Florida International University Acknowledgments FIU Faculty: Jim Jaccard, Bill Kurtines Past Post docs: Steve Berman (UCF), Golda Ginsburg (Johns Hopkins), Brian Rabian (Penn State), Andreas Dick-Niederhauser (Bern, Switzerland) Current Post docs: Carla Marin,Yasmin Rey Current FIU graduate students: Ayce CiCi-Goltkun, Jessica Dahan, Cristina Del Busto, Irina Fredricks, Devi Hausman, Maria Pienkowski, Ileana Hernandez, Luci Motoca, FIU undergraduate students NIMH Research Grants: R29MH44781, R01MH49680, R21MH 54690, R01MH63997, R01 MH079943 NIMH Midcareer Development Award: K24MH73696 Additional Acknowledgments Anne Marie Albano CAMS Team (Golda Ginsburg) Debbie Beidel Eliot Goldman Christopher Kearney Phil Kendall Ron Rapee Tom Ollendick Michael Southam-Gerow The Reach Institute (Peter Jensen and colleagues) Workshop Overview Prevalence Diagnosing and assessing Etiological theories Overview of treatment Treatment nuts and bolts Cases and questions Background Information Anxiety disorders of childhood and adolescence are one of the most, if not the most prevalent problems. Most prevalent problems in adults. PREVALENCE OF CHILD DISORDERS (ANDERSON ET AL. ,1987) DIAGNOSIS OPPOSITIONAL PERCENT 2.2 : 1 5.7 SEPARATION 3.5 CONDUCT 3.4 OVERANXIOUS 2.9 SIMPLE PHOBIA 0. 2.4 MOOD 1.8 SOCIAL PHOBIA 0.9 ALL CONDUCT 2.8 : 1 9.1 ALL ANXIETY 0.7 : 1 9.7 Demographic Factors AGE – Any (onset around ages 5 to 7) SEX – Both boys and girls, with age > girls ETHNICITY/RACE – Any SES – Any MARITAL – Any FAMILY SIZE – Average PARENTS – Higher in anxiety Anxiety problems are highly prevalent, but… least likely to be detected and referred Why the low detection and referral rates? The Internalizing versus Externalizing distinction (the kids who cause the ‘trouble’ get our attention). Assumption that most childhood anxiety is a transient or temporary, fleeting event. Transient episodes of anxiety Are expected and cause relatively little interference in functioning for the average child or adolescent Are associated with new or unexpected events (e.g., thunder; first day of school) Can be handled with minimal reassurance or encouragement But anxiety disorders in children do not necessarily remit over time. Anxiety disorders are also associated with substantial impairment Family Friends School Personal Distress Assessing for impairment… FISH Frequency? Every day? once a week? Once a month? Intensity or Severity? How long has this been going on? A week? A month? Duration? Get a rating! Rates of Diagnosis and Impairment (N=1,015; ages 9, 11, 13) Diagnosis/ Impaired 13.7 % Diagnosis/ Not Impaired Impaired/ Not Diagnosed 14 % 20 % from Angold et al. (1999) Gateway to other Psychopathologic Conditions: Developmental Patterns in Onset Specific phobia Separation anxiety disorder Social phobia Generalized anxiety disorder Panic disorder Depressive disorder Substance use disorder Anxiety disorders also are associated with suicidal ideation (Carter, Silverman et al., 2008) Summary reasons for treating anxiety disorders in youth Quiet distress and significant impairment Do not remit with time “Gateway” to other disorders including anxiety disorders, dysthymia/depression, and substance use/abuse problems Successful implementation of evidence based anxiety treatment depends on careful conceptualization and understanding of child’s anxiety problems DIAGNOSIS & ASSESSMENT OF ANXIETY DISORDERS DSM-IV Anxiety Disorders Other disorders of Infancy, Childhood, or Adolescence ◦ Separation Anxiety Disorder Anxiety Disorders ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Specific Phobia Social Phobia (Social Anxiety Disorder) Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Generalized Anxiety Disorder Panic Disorder with Agoraphobia Panic Disorder without Agoraphobia Agoraphobia without History of Panic Disorder Sue Sue, a 4th grader, has stopped attending school. She went the first couple of days with a huge fuss in morning, which continued for a few hours in the classroom. Parents were told that Sue can’t stay in school if this is how she is going to behave. Now things have gotten worse and now she refuses to even get out of bed in the morning. She vomits at night and reports having terrible stomach aches in the morning. She is afraid to sleep alone in her bedroom at night; she has been sleeping in her parents’ bed for over two years. Separation Anxiety Disorder Fear of separation from major attachment figures (possible harm) Avoidance of being left alone Excessive worry about separation Physical symptoms on separation Common fears ◦ Going to school ◦ Being left with sitter ◦ Sleeping away from home Kevin Kevin, just transitioned from elementary school to middle school. He is beginning to show increases in absenteeism. When carefully questioned, he revealed that he ‘can’t handle’ the idea that kids are probably laughing at him behind his back. He says ‘he hates having to walk through the hallways between classes, knowing that other people are looking at him.’ He worries constantly what the other kids are thinking about him and he is worried that he might say something or do something ‘dumb’. Social Phobia Fear of doing something embarrassing Avoidance of situations involving potential evaluation Worry about what others think Self consciousness Limited friends Common fears: ◦ ◦ ◦ ◦ Meeting new people Speaking in groups (class) Speaking to authority (teachers) Standing out Antonio Antonio, a 3rd grader, is worried about the FCATs and other tests. On Fridays, test days, the teacher notices that he looks upset and almost as though he might break down and cry. He reports a fear of not being able to move on to 4th grade if he does poorly on the FCAT. He constantly asks his mother and teacher for reassurance that he won’t be retained. No matter what Antonio is told, he still worries. Antonio performs satisfactorily (grade level) in math and reading. He is often absent due to frequent headaches, especially on Fridays. Generalized Anxiety Disorder Excessive worry about everyday life issues Excessive reassurance seeking Stomach aches, headaches, etc. Irritability, poor concentration Common fears: ◦ ◦ ◦ ◦ novelty Making mistakes Performance (school sports) Negative news Social Phobia vs. GAD Social Phobia ◦ Worry is focused on performance and social/evaluative situations ◦ The anxiety dissipates upon avoidance or escape of the situation ◦ Difficulty making or keeping friends ◦ Focus is on what other people think GAD ◦ Worry in areas other than performance or interpersonal ◦ The worry does not stop, even with active avoidance or escape ◦ Friendships are not typically problematic ◦ Focus is usually on a self-imposed, unrealistic standard Social Phobia vs. SAD Avoiding social situations because child does not want to be separated by parent (SAD) versus child stays away because of excessive fear of social evaluation (Social Phobia). Other common anxiety related problems Selective Mutism School Refusal Behavior Test Anxiety Selective Mutism Consistent failure to speak in specific social situations, such as school, despite speaking in other situations Interferes with educational functioning or with social communication Symptoms must last at least one month Mutism not due to lack of knowledge or comfort with spoken language Mutism not due to communication disorder, pervasive developmental delays, or psychosis Additional Features (subtypes?) Excessively shy/timid/sensitive/inhibited Fear of social embarrassment Social isolation and withdrawal Clingy/reticent Compulsive traits/anxious Negativism/depression Temper tantrums Controlling/oppositional behaviors Traumatized Is selective mutism a more severe form of social phobia? % with SP Diagnosis Kristensen (2000) 68% Manassis et al. (2007) 62% Arie et al. (2006) 44% Black & Uhde (1995) 97% Vecchio & Kearney (2005) 100% School Refusal Behavior Consists of youth who are completely or partially absent from school OR who show morning misbehaviors to avoid school OR attend school under significant distress Prevalence average - 8.2% of population Equally seen in boys and girls Most common age of presentation – 10 to 13 years More common among minority populations School Refusal Behavior (heterogeneous problem) Wants/needs to be with mom? (Separation Anxiety Disorder, 60%) Can’t escape if have a panic attack? (Panic Disorder with Agoraphobia, 60%) Excessive and uncontrollable worry about things (Generalized Anxiety Disorder, 30%) Social evaluation of kids, teachers (Social Anxiety Disorder, 20%) Irrational fear about something specific (e.g., loud sound of school bell; Must pass a large dog on way to school) (Specific Phobia, 20%) Test Anxiety (heterogeneous problem) Prevalence - 10 to 41% in school age children Girls report significantly higher test anxiety than boys African Americans report significantly higher test anxiety than European Americans Test Anxiety “I need to be perfect. I won’t get into college.” (Generalized Anxiety Disorder) “Others will think I am dumb. My teacher/mom will be disappointed in me.” (Social Anxiety Disorder) “Taking tests makes me scared (and only tests).” (Specific Phobia) “I may get those panic attacks during the test.” (Panic Disorder) Does test anxiety affect high stakes test scores? Yes: in a sample of African American elementary school children, children who reported high levels of physical symptoms of anxiety and social anxiety symptoms also reported high levels of test anxiety. These children, in turn, received low achievement levels on the FCAT reading (Carter, Silverman, & Jaccard, 2011) Guide for Diagnosing Anxiety Disorders Interview Schedule for Children ◦ Child and Parent Versions ◦ Reliability data ◦ Interference ratings for primary, secondary, etc. Separation Anxiety Disorder Social Phobia Social Phobia Screening Measures Multidimensional Anxiety Scale for Children (March et al., 1997) Screen for Child Anxiety Related Emotional Disorders (Birmaher et al.,1997) Spence Children’s Anxiety Scale (Spence, 1998) Spence Children’s Anxiety Scale www.scaswebsite.com 38-item questionnaire Child version for ages 8-15 Parent version for ages 6-18 Responses are scored: ◦ ◦ ◦ ◦ Never = 0 Sometimes = 1 Often = 2 Always =3 Spence Children’s Anxiety Scale Interpretation – Child Version Spence Children’s Anxiety Scale Interpretation - Parent No T-scores available Norms for anxiety disordered and nonclinic referred children available on website Parent Ratings Child Behavior Checklist (CBCL) Subscales * CBCL Internalizing T * CBCL Anxiety/Depression Scale * CBCL-A (anxiety-specific scale) Reliability data Teacher Ratings Teacher Report Form (TRF) Subscales * TRF Internalizing T * TRF Anxiety/Depression Scale * CBCL Withdrawn Scale * CBCL-A (anxiety-specific scale) Reliability data ETIOLOGY AND MAINTENANCE OF ANXIETY DISORDERS Hypothesized Risk Factors for Phobic and Anxiety Disorders Genetics Temperament Learning Pathways Cognitive Influences Parental Influences Neural Circuitry Genetics Anxiety is clearly heritable, but the precise heritability depends on numerous factors including type of anxiety, the age and sex of the population, how anxiety is assessed, and whether anxiety is considered as a personality trait or a psychiatric disorder. Temperament: Behavioral Inhibition A temperamental characteristic, observable as early as toddlerhood, consisting of a relatively stable tendency to be cautious, quiet, and behaviorally restrained in situations of novelty. Estimated to occur in 10% to 15% of children. Learning Classical Conditioning ◦ Little Albert Operant Conditioning Vicarious Conditioning ◦ Rhesus Monkeys Information Transfer ◦ Being told something was dangerous Youth Who Reported “A Lot” of Fear and Three Pathways of Acquisition Fear Item Direct Conditioning Modeling Information/ Instruction Not able to breathe 30% 46% 76% Hit by car or truck 12% 66% 92% Fires 5% 59% 96% Snakes 34% 65% 89% Earthquakes 6% 43% 93% Note: Percents do not add up to 100 since subjects could endorse more than one source of fear. (Ollendick & King, 1991) Cognitive Influences Distorted - mistaken processing - Dysfunctional distortion -Functional distortion Deficiencies - absence of processing The links among cognition, behavior, and emotion Cognitive deficiencies - externalizing behavior and limited emotional distress Cognitive distortions - internalizing behavior and greater emotional distress Cognitive Dysfunction Disorder Distortion Deficiency Anxiety 6 0 Depression 9 0 ADHD 0 9 23 27 Aggression Parental Influences Parenting Skills - less granting of psychological autonomy (over-controlling) and more encouraging of avoidant behaviors (over-protective) Mother -Child Relationships - negative and critical Father – Child Relationships - limited risk-taking play behavior; unpredictable, punitive, explosive Neural circuits…. Genetic Influences A. Brain Circuits B. Psychological Processes Dorsal PFC-Based Circuits Working Memory PFC-Striatum-Based Circuits Response Inhibition Ventro-lateral PFCAmygdala-Based Circuits Threat Influences on Attention Orienting C. Phenotype Groups of… Psychotic Disorders Behavior Disorders Anxiety Disorders Environmental Influences Evolving over the context of development Fig. 1 Schema of mechanisms underlying associations among neural circuits (A), psychological processes (B), and clinical phenotypes (C), as influenced by genes, environments, and development. PFC = Prefrontal Cortex. Pine et al. 2008 EVIDENCE-BASED TREATMENTS FOR CHILD ANXIETY DISORDERS EBTs for Child Anxiety Disorders Research Over 25 randomized controlled clinical trials have been conducted. Cognitive Behavioral Treatment Cognitive-Behavioral Treatment of Anxiety Disorders in Youth Behavioral: practice exposure tasks in session and out of session, positive consequences for successful efforts (rewards) Cognitive: concern with information processing, self statements, Emotional: addresses feelings Social: involves parents and can involve peers Cognitive-behavioral is not… A passive therapist A know it all therapist An unimportant therapeutic alliance A cookbook approach or ignoring of emerging issues Providing interpretations but helping child to develop understanding of generalizations of his/her behaviors, thoughts, feelings Treatment Formats Group Individual Parent Involvement CBT for Anxiety Disorders Education Phase Application Phase Relapse Prevention Phase Adjunctive Strategies (e.g., relaxation skills, social skills, time management skills) Education Phase Collaborative or joint effort Tri-partite view of anxiety (behavioral, cognitive, physiological) Rationale of treatment and key change-producing procedure - exposure Devise fear/anxiety hierarchy Behavioral procedures ◦ Contingency management ◦ Parent training Cognitive procedures ◦ Child self-control training and cognitive restructuring Application Phase Gradual exposure tasks: in-session and out-of- session Use of behavioral and cognitive procedures Use of adjunctive strategies Practice and review Relapse Prevention Phase Emphasize importance of Practice, Practice, Practice Handling slips Role of Therapist Coach Consultant Collaborator (in developing tasks; in understanding shared experiences) Tri-partite view of anxiety Behavioral Cognitive Physiological HOW ANXIETY SHOWS ITSELF? Thoughts Bodily Reactions Behavior -- AVOID Rationale of treatment…. Links of thoughts, feelings, and behaviors DAILY DIARY What happened? What Were My Thoughts? My Fear Rating? Key change-producing procedure Exposure Conducted in graded or gradual fashion Either live/in vivo or imaginal Exposure All current EBTs for anxiety disorders include the need for child coming into contact with the feared object, situation, or event Exposure is a procedure, not the scientific basis for fear reduction “Typical” Anxious Response* 7 6 SUDS 5 4 Anxiety 3 2 1 0 Base 5 10 TIME SUDS, subjective units of distress *This is a hypothetical clinical illustration. 15 How Feeling Better Can Make Anxiety Worse Two-Factor Theory of Acquisition/Maintenance When an individual repeatedly confronts a fearproducing situation, the fear response is strengthened through the process of classical conditioning Avoidance behavior is reinforced through the process of operant conditioning (negative reinforcement) SUDS Within Session Habituation* 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 SUDS 0 10 20 30 40 50 60 Time of Session *This is a hypothetical clinical illustration. 70 80 90 Between Session Habituation* Session # *This is a hypothetical clinical illustration. Other theoretical models for why Exposure? Allowing child to re-experience the anxiety or fear provoking event in a safe, secure environment enhances child’s feelings of self efficacy, competency, and coping Cognitive restructuring is made more relevant by addressing the anxious automatic thoughts that are elicited during exposures. Possible diagnoses/targets for exposure Specific Phobia (dogs) – Expose child to different types of dogs in different contexts Social Anxiety Disorder – Expose child to social situations such as speaking in groups Separation Anxiety Disorder – Expose child to separation situations Generalized Anxiety Disorder - Expose child to situations that will provide incompatible information with worries To What is One to be Exposed? The core fear(s): ◦ Emphasize need for thorough understanding of the psychopathology ◦ And need to conduct a thorough assessment Conducting In Vivo Exposures Assess baseline anxiety or fear ratings using Fear Thermometer (or subjective units of distress; SUDS) Expose at highest level child agrees on that for that session or between sessions (“worst fear”) Obtain fear or SUDS ratings few times during exposure tasks Try to stay in situation until ratings return to baseline (within session habituation) Do not allow coping or distraction Repeat until situation no longer elicits distress (between session habituation) Conducting Imaginal Exposures Determine if imagery can be used Conduct imagery training if necessary Construct scenes with child assistance especially including “core fear” Scene should include all aspects of fear including physiology and negative cognitions Conduct session Differences Between Treatment and Natural Encounters with the Phobic Object Natural Encounters ◦ ◦ ◦ ◦ ◦ Unplanned Ungraded Uncontrolled Very Brief Patient Alone Therapy Situation ◦ ◦ ◦ ◦ ◦ Planned Graded Controlled Prolonged Team Work Doing Effective Exposure The team work relationship The therapist will never do anything unplanned in the therapy room. ◦ Description ◦ Demonstration ◦ Permission to do it A high level of anxiety is not a goal in itself. Doing Effective Exposure (cont) The child makes a commitment to remain in the exposure situation until the anxiety fades away. The child is encouraged to approach the phobic stimulus and to remain in contact with it until the anxiety has decreased. The therapy session is not ended until the anxiety level has been reduced. Doing Effective Exposure (cont) The exposures are set up as a series of behavioral tests or experiments. The child’s catastrophic cognitions concerning what might happen upon presentation of the phobic stimulus is confronted and challenged. Education Phase Meet with parents alone to discuss: ◦ ◦ ◦ ◦ Encouraging courageous vs. anxious behavior Breaking down anxious or undesirable behavior Non-physical punishment Distinguishing between anxious and oppositional behavior General rules for creating hierarchies Get list from child (and check in with parent as necessary) of all the situations and the particulars of the situations that are hard for him/her Get the details such as duration of time; frequency during week; anyone accompanies child?; who is around; etc. Ensure list contains very easy to very hard Once items for list is obtained put items in order from easiest to hardest Rank each item from 1 to 8 THE LADDER 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 General rules for creating hierarchies (cont.) Unlikely to need to conduct exposures that are 1 and 2; probably start with 3 or 4 (depending on case) Ensure that the “hardest” items (e.g., 8) are situations and tasks that are important to do for “successful” treatment General rules for creating hierarchies (cont.) Typically, situations provided by child/parent need to be “broken down” further because to difficult to do as one step Need to decide with child/parent which areas are interfering most and therefore should take priority for targeting in treatment Fear Hierarchy – Social Phobia Feared Situations Fear Ask someone (not friend) to be partner in class 8 Ask to play with a group of kids at playground 7 Give friend birthday present and say hello to parents at party 6 Ask someone to sit with me at lunch 6 Say hello to friends at school 5 Say hello to mothers at school 4 Fear Hierarchy – Agoraphobia Feared Situation (from ADIS) Fear School cafeteria 7 Classroom 7 Movie theaters 6 Waiting in line at store 6 Public transportation (e.g. train) 5 Restaurants 5 Church or temple 4 Stores or malls 4 “Breaking hierarchy down” (as necessary) Perhaps “Stores or malls” is difficult to do in one shot; need to break down into smaller steps Find out if “stores or malls” make a difference Which is easier? Which is harder? Stores Make a trip back and forth to store (no entry) Walk into store and walk right out Walk into store and stay for xx minutes Walk into store and stay for xxx minutes Walk into store and buy something Etc…. Fear Hierarchy – Social Phobia Feared Situation (from ADIS) Fear Oral reports/reading aloud 8 Asking the teacher a question 7 Asking the teacher for help 6 Joining a group of kids 6 Starting or joining a conversation (w/ classmates) 6 Inviting a friend to get together 5 Fear Hierarchy – Joining a group (perhaps add minutes…) Feared Situations Fear Participate in meeting 7 Meet someone at meeting 7 Go to meeting – sit in front 6 Go into meeting – sit at side 5 Go to setting 5 Making a longer inquiry 4 Making a short inquiry call 3 Looking up information 2 Fear Hierarchy – Specific Phobia of Dogs Feared Situation Fear Petting a large dog that is running loose 8 Going over to a friend’s house and staying in the same room with the dog loose 7 Petting a medium size dog which is running loose; 7 Allowing a medium size dog which is on a leash to lick his hand 6 Petting a medium size dog which is on a leash 5 Going to a pet shop and petting a small puppy which is being held by somebody 5 Going to a pet shop and looking at a dog through the window 4 Fear Hierarchy – Separation Anxiety Disorder Feared Situation Fear Stay home alone (60 mins) 8 Stay home alone (30 mins) 7 Ride bus alone (all week) 7 Ride bus alone (2 times) 6 Stay after school without friends 6 Take out trash at night alone 5 Stay alone in bedroom (30 mins) 5 Stay alone when someone is in the shower 4 Contingency Management - Parent-Child Contracts (facilitate exposures) Let it be known that on this Tues day, the 24 of May in the year 2001, a contract between (child’s name) and mother/father (parent’s name) concerning the child’s fear of being in crowded places was signed, witnessed by Dr. Silverman. The above parent and child hereby agree that if (child’s name) successfully stays in Dadeland Mall for 15 minutes with Mom then (child’s name) will stay up an extra ½ hr on Thursday night. This task is to be done by the child on Thursday, and the parent is to give child the above mentioned reward on Thursday. Parent training The “Protection Trap” Importance of getting out of the trap by attending to, or rewarding, child approach or nonavoidance Parents as models Mastery modeling: demonstrating successful performance from onset **Coping modeling: demonstrating strategies to overcome the problem, then demonstrating successful performance Cognitive Strategies Self control training and coping Changing self-talk Problem solving Self control training and coping Self observation Self change (modify behavior, thoughts, self talk) Self evaluation and reward Scared? Thoughts Other thoughts or Other things I can do Praise My T’s and My O’s My T’s My O’s Common Cognitive Distortions Magnification Minimization Overgeneralization Selective Abstraction Catastrophizing (“what if…”) (Importance of non-negative thinking, not necessarily positive ……) THINKING TRAPS Burnt Cookie Concept Catastrophizing Fortune Telling Over-generalizing First report Card Second Report Card Math: B- Mind Reading Math: ? “Should”ing “I should this…. I should that… I should this… I should that… I should this…” Perfectionism Third Report Card Math: ? Changing Self Talk Gather evidence by asking yourself the following questions… 1. Do I know for sure this is going to happen? 2. What else might happen, other than what I first thought? 3. Has it happened before? 4. Has this happened to anyone I know? 5. How many times has it happened before? 6. After collecting the evidence, what are the odds of ___________? 7. So, what is a coping thought I can have in this situation? Additional questions to consider: 1. Is worrying about this helping? 2. What am I missing out on because I am worrying? Optimizing gains Assessment and targeting the core fear(s) Directed discovery Involvement Cooperation/collaboration Relapse prevention (dealing with frustration) Working for generalization Arranging termination Individualizing the program Therapist flexibility (within fidelity) Interfering with gains Teachy-preachy style Forcing youth to talk about feelings (Creed & Kendall, JCCP, 2005) Excessive focus on tasks Mechanical self-talk “Wimpy” exposures Way too scary exposures Child depression? Conflictual relations? For more information, please go to the main website and browse for more videos on this topic or check out our additional resources. Additional Resources Online resources: 1. Society of Clinical Child and Adolescent Psychology website: http://effectivechildtherapy.com/sccap/ 2. Spence Children’s Anxiety Scale: www.scaswebsite.com Books: 1. Silverman, W.K. & Field, A. P. (2011). Anxiety Disorders in Children and Adolescents (2nd Ed.)New York, NY: Cambridge University Press. 2. Silverman, W.K., & Albano, A.M. (1996). The Anxiety Disorders Interview Schedule for Children for DSM-IV: (Child and Parent Versions). San Antonio, TX: Psychological Corporation. Peer-reviewed Journal Articles: 1. Carter, R., Silverman, W.K., & Jaccard, J. (2011). Sex variations in youth anxiety symptoms: Effects of pubertal development and gender role orientation. Journal of Clinical Child & Adolescent Psychology, 730-741. 2. Creed, T. A., & Kendall, P.C. (2005). Therapist alliance-building behavioral within a cognitive-behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73(3), 498-505. 3. Ollendick, T., & King, N.J. (1991). Origins of childhood fears: An evaluation of Rachman’s theory of fear acquisition. Behaviour Research and Therapy. 29(2), 117-123. 4. Pine, D.S., Helfinstein, S. M., Bar-Haim, Y., Nelson, E., & Fox, N. A. (2008). Challenges in developing novel treatments for childhood disorders: Lessons from research anxiety. Neuropsychopharmacology, 34,213-228. 5. Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37, 105-130.