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Chapter 7
Anxiety, Posttraumatic Stress, and
Obsessive-Compulsive Disorders
Defining Fear and Anxiety
• Problems of anxious children much less
obvious, more difficult to assess
– Fear – strong emotional alarm reaction to real
or perceived danger. Sympathetic nervous
system stimulates flight or fight response
– Panic – sudden overwhelming state of extreme
terror or fear
– Anxiety – persistent concern about danger in
the future
Children’s Common Fears
• 0-12 months – loss of support, loud
unexpected, looming objects, strangers
• 12-24 months – separation from parent,
strangers, injury
• 24-36 months – separation from parents,
animals, darkness
• 3-6 years separation from parents, strangers,
animals, darkness, injury
• 6-10 years – darkness, injury, being alone,
imaginary beings
• 10-12 years – injury, social evaluations,
school failure, ridicule, thunderstorms,
death
• 12-18 years – school failure, peer rejection,
family problems, wars, future plans
Sources of fears
• Physical and cognitive limitations
• Observing other people’s fearful reactions
• Adult’s warnings about potential threats
Phobias
• DSM-IV-TR recognizes that children’s
phobic symptoms differ from those of adults
• Criteria for assessment includes age,
duration, intensity, and type of fear
Separation Anxiety Disorder
• When a child grows less rather than more
tolerant of separations from one or both
parents
• One of most common childhood problems
– Show excessive age-inappropriate worries
about separation
– School refusal can be a form (DSM-IV)
although some classify as separate
Generalized Anxiety Disorder
• Uncontrollable, excessive anxiety and worry,
occurring consistently for 6 months, extending to
many events and activities
• Child shows one of following in extreme form:
–
–
–
–
–
Irritability
Restlessness
Fatigue
Difficulty in concentrating
Muscle tension or sleep disturbance
• Child may be insecure, perfectionist
(resembles OCD)
• Accompanied by depression
• Widespread anxiety in many different
situations
Posttraumatic Stress Disorder
• Experienced by people who have
experienced an extremely devastating event
• Persistent and unwilling re-experiencing of
traumatic event, persistent attempts to avoid
all thoughts and acts related to the event,
and a high state of arousal
• Children can develop PTSD even if not
directly physically threatened
• Children who lose a parent at particular risk
• Important gender and developmental
differences in how people react to
catastrophic events
– Girls 5 times more likely than boys
Symptoms
• May develop immediately or months/years after
event
• Disorganized, agitated behavior
• Persistent mental experiencing of event followed
by long periods of avoidance and emotional
numbing
• Avoidance of anything associated with event
• Exaggerated startle responses, hyper alertness
Treatment
• Limited research suggests immediate relief
comes from support of teachers and
classmates
• Parents and teachers need to convey sense
of calm and control
• Cognitive-behavioral therapy
• Family/group treatment
Diagnosis
• Difficult to diagnose
– Overlap of symptoms of anxiety, mood and
other internalizing disorders
– Depends heavily on self-reported anxiety, fear
or depression, difficult for young children
Social Anxiety Disorder, or Social
Phobia
• Average onset is 15 years
• Marked by extreme self-consciousness and
incapacitating anxiety in social situations
• Occurs twice as often in women as men, but
men are more likely to seek help
• Complaining about pervasive fear of being
observed, judged negatively
• Constant concern about inadvertently doing
things that are humiliating
• Worry far in advance of social situations
• Peaks at informal gatherings rather than at
formal situations or presentations, which are
highly scripted
Vicious Cycle
• Social phobic children are less socially
skillful
• Draw negative reactions from peers
• Undermines self-confidence, leading to
further social failures
School-Related Avoidance Disorders
• Not in DSM-IV as separate disorder, but as
symptom of separation anxiety
• Persistent avoidance of school motivated by
intense fear and anxiety
• Can stem from specific phobia
• Can indicate generalized anxiety or
separation anxiety
• Perfectionists displaying excessive concerns
about academic performance
• Can arise from modeling of anxious,
overprotective parents, anxiety disorder or
specific phobia
Two Types of Refusal
• Mild acute school refusal
– Affects younger children, little or no family
discord, sudden onset
– Rapid return to school is most used treatment
• Severe chronic school refusal
– Typical in children over 11 from unstable
families
– Parents may be overcontrolling
Management of School Refusal
• Mild form best treated by parents’ firm,
supportive insistence that the child
gradually return to school
• Severe form often accompanied by other
disorders and requires professional
intervention
– Complexity requires assessment and therapy
tailored to individual child
Etiology of Anxiety Disorders
Psychodymanic Theory
• Freud – psychologically created tension,
anxiety, guilt, sexual jealousy
• Present day theory loosely based on
psychoanalysis, but emphasizes importance
of social rather than sexual interactions
– Phobic person wants to be center of attention
– Child develops specific phobia or anxiety as a
way of expressing an unacceptable desire
Social Learning and Cognitive
Approaches
• Research based and emphasizes role of
modeling in development of fears
• Bandura’s Self-efficacy theory:
– People don’t develop fears so much from fright
paired with sight of feared object as from
anxiety that they cannot successfully avoid
feared object and protect themselves
– Lack of self-confidence leads to dwelling on
possibility of losing control
• Children don’t necessarily fear things that
can harm them (automobiles, drowning)
• Parents need to teach children realistic fears
and help them overcome unrealistic ones
Biological Contributors
• Hints in recent research suggests that there may be
complex multiple gene contributions to anxiety
and panic disorders
• Children of mothers, but not fathers, who have a
lifetime history of anxiety disorder are doubly at
risk
• Research suggests that stable differences in brain
activity may characterize certain children as
susceptible to anxiety disorders
Prognosis for Children with Phobias
and Anxiety Disorders
• Most early phobias are quickly and
effectively treated by
• Prognosis is worse for those with severe
anxiety disorders
– When they persist only 20% are eventually
overcome
– Fear of physical illness and social anxiety
disorder tend to persist throughout life
Psychological Interventions
• Psychodynamic Therapies
– Child encouraged to act out fears and fantasies
in therapy sessions
– Analyst interprets meaning of fantasies
– Childs troubling unconscious feelings
transferred from parent to analyst
– Phobic reactions disappear without specific
intervention when psychological conflicts have
been resolved
• Critique:
– Expensive and time consuming
– Some aspects have become incorporated into
mainstream of child psychotherapy
Desensitization Therapy
• Takes place in gradual steps
• Focus on child’s learning to relax in stressinducing circumstances by going through fear
hierarchies from mild to most severe
• Relaxation used to counteract the muscular
tension of anxiety
• Drawback: doesn’t teach child to deal with what
they fear, so needs to be coupled with other
treatments
Modeling and Guided Participation
• Effective in treating children's specific
phobias especially when limited to a
particular situation
– Modeling: Child’s confidence built by watching
someone else deal with feared stimulus
– Guided Participation: Carefully supervised
confrontations with feared stimulus in natural
environment
Cognitive-Behavioral Treatments
• Multifaceted cognitive-behavioral treatment
very effective, and rigorously tested.
Techniques include
– Modifying anxious self-talk
– Teaching problem solving and behavioral
strategies
Obsessive-Compulsive Disorder
• Common rituals or routines reassure young
children and provide sense of security
• Pathological obsessive-compulsive behavior
consists of attempts to reduce severe
anxiety and involves unusual activities
– Hand washing
– Bathing
– Scrubbing already spotless surroundings
Compulsive Children
• Compulsions can develop without
obsessions
• Rituals involving washing, repeatedly
arranging objects, or checking on location
of certain objects over and over
• Compulsive children may develop phobias,
depression, and neurological conditions
Obsession
• Obsessions usually accompany other
problems (phobias, depression)
• Likely to persist through life
DSM-IV-TR diagnostic criteria
• Obsessions and compulsions are senseless
repeated thoughts, images, or impulses
(obsessions) or repetitive acts (compulsions) that
are:
– Unrealistic and dysfunctional
– Experienced as unwelcome but irresistible
– Experienced as products of one’s own mind rather than
external threats
– Ritualistic and stereotyped
– Time-consuming
– Disruptive of everyday activities
Typical features for youngsters
• Obsessive themes – contamination,
aggression, maintaining ultra strict order,
fear that family members might be killed
• Compulsions – checking under bed
constantly, wipe possessions repeatedly,
tapping. Most engage in rituals at home and
try to hide them
Treatment of Obsessive-Compulsive
Disorder
• Cognitive-Behavioral therapy – most
recommended treatment, alone or combined
with an SSRI
– Contact with anxiety-provoking event followed
by guided, prolonged exposure to feared
stimulus, or
– Sudden exposure to feared stimulus. To
demonstrate that compulsive behavior is not
necessary
Drug Treatment
• Fluvoxamine – well tolerated and acts
rapidly in short term
• Long-term effects unknown