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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