- Generalized Anxiety Disorder
- Panic Disorder
- Obsessive Compulsive Disorder
- Social Anxiety
- Separation Anxiety/School Anxiety
- Depression/Mood Disorders
Other Childhood and Adolescent Disorders Related to Anxiety and Depression
Generalized Anxiety Disorder (GAD)
GAD involves an excessive worry, occurring more days than not, for at least six months, about a number of events or activities, such as work or school performance; There is difficulty controlling the worry and the worry is associated with multiple physical symptoms. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning (American Psychiatric Association).
Up to 10 percent of the school age population is likely to have mild anxiety (sensitive children) while 2 percent of the school age population meet diagnostic criteria for Generalized Anxiety Disorder (Association of Anxiety Disorders).
Anxiety is a “fight or flight” response and is associated with the perception of danger, threat or vulnerability. Cognitive therapy helps parents and children to identify, evaluate and alter thoughts and beliefs associated with anxiety the child is experiencing.
Without treatment, Generalized Anxiety Disorder can be chronic and persistent throughout lifetime. Cognitive therapy, relaxation training and behavioral therapy have demonstrated in research studies to be very effective in the treatment of Generalized Anxiety Disorder in children (Manassis, 2008).
Panic Disorder is the experience of panic attacks followed by ongoing concern and worry about having another panic attack and/or worry about the possible consequences of a panic attack. There may be avoidant behaviors associated with, and secondary to, the panic attacks. Often associated with a panic attack is a catastrophic misinterpretation of a physical sensation. These catastrophic misinterpretations include thoughts such as “I’m having a heart attack” “I’m going to die” or “I’m having a stroke”. These catastrophic thoughts further create anxiety which increases the physical sensation and strengthens the catastrophic misinterpretation.
Cognitive/behavioral therapy has shown to be effective in the treatment of Panic Disorder. Therapy consists of parental and adolescent instruction in relaxation exercises and teaching adolescents to identify evaluate and alter the thoughts that are associated with their panic attacks. This is often combined with systematically approaching situations or experiences that are being avoided because of fear of having a panic attack.
Outcome studies have shown that cognitive/behavioral psychotherapy is very effective in treating Panic Attacks and Panic Disorder in adolescents and adults. Panic Disorder rarely occurs in children.
Obsessive Compulsive Disorder
Obsessive-Compulsive Disorder is likely to affect 2% of the child and adolescent population at some point in their life. The disorder is equally common in males and females.
Adapted from the Diagnostic and Statistical Manual of Mental Disorders – IV-TR.
Obsessions are distressing and persistent thoughts that are associated with anxiety. Obsessive thoughts frequently have a theme of contamination (germs or dirt), or doubts over something that was said or done. Many children have obsessive thoughts that have to do with rules and fairness, and contain magical or unrealistic thinking.
Compulsions, on the other hand, are behaviors or actions that are designed to reduce the anxiety associated with the obsessive thought. Compulsive behaviors are repetitive actions (behaviors) that are also designed to prevent a dreaded consequence from occurring. Compulsive behaviors include repetitive washing or cleaning, showering or doing some other activity in a particular order, checking, double-checking and triple-checking, etc., repeating phrases or thoughts or redoing actions. Compulsive behaviors frequently result in a reduction of anxiety and a temporary sense of feeling good. The most common compulsive behaviors are washing and checking.
Treatment of Obsessive Compulsive Disorder
The behavioral treatment of Obsessive-Compulsive Disorder consists of three components – exposure, response prevention and cognitive (thoughts and beliefs) therapy. Exposure involves systematic, gradual contact or exposure to events in which the obsessive thoughts and -compulsive behaviors are likely to occur. For example, a child with a fear of contamination from germs would be helped (by parents, teachers and therapist) to gradually come in contact with germs via petting a dog or a cat. This could be combined with the response prevention component of the treatment which is to not engage in the usual compulsive activity which, in this example, may be hand washing. Variations on response prevention include response delay or response restriction. Response delay means delaying immediately washing the hands for longer and longer periods of time. Response restriction, means limiting the amount of time that the hands are washed. One of the purposes of the exposure and response prevention is to see if the fear or anxiety diminishes with time and without the compulsive behavior.
The cognitive (thoughts and beliefs) component of treating OCD involves assessing and understanding the result of the exposure and response prevention exercises described above. For example, how does the child explain the fact that no disease was contracted despite touching the dog or cat, and not washing for a significant period of time? Does this new experience cause the child to rethink their assumptions about their vulnerability and the purpose of their compulsive behaviors? The cognitive therapy component of treating OCD is also designed to teach children and their caretakers’ new thinking methods and strategies that can help the child identify and alter the interpretations that they have of their obsessions.
Treatment of OCD also involves learning, practicing and implementing anxiety management strategies including progressive muscle relaxation, mental imagery or deep breathing. Becoming proficient in these relaxation strategies can make it easier for the child to approach feared and anxiety producing situations.
Cognitive behavioral therapy has shown to be effective in the treatment of Obsessive-Compulsive Disorders in children and adolescents.
Social anxiety is painful and anguishing for a child and or adolescent. It can interfere with social functioning, and relationships. Shy children often avoid situations where they might be judged. Avoidance is the behavior most often associated with social anxiety. Most people would not willingly or easily put themselves in a situation where they believe they will be judged negatively and children may protest when adults attempt to force them into social situations (Manassis, 2008).
Cognitive Behavioral Therapy of Social Anxiety
The goal of CBT for social anxiety is often increased social interaction with minimal anxiety. Successful treatment may result in the ability of the child to interact in any group or social situation without anxiety and with little or no concern about being evaluated or judged. Successful treatment may result in the elimination of avoidance behaviors.
Social anxiety disorder is very treatable. Psychotherapy research studies have shown that CBT is an effective treatment for anxiety disorders in general and social anxiety in particular.
Separation Anxiety/School Anxiety
For many families the first days of school are met with excited anticipation of new friends, new teachers, and new experiences. However as many as 5% of school aged children refuse to attend school based on fears and anxiety. Emotional meltdowns and anxiety may occur at school, in the car on the way to school, when getting out of bed in the morning or even the night before school. A common scenario is parents desperately attempting to get their fearful, emotionally distraught child out of the house, into the car or out of the car and into the school. Psychologists call this by various names including separation anxiety, school refusal or an anxiety disorder.
What is School Refusal?
In young children, in order to understand school refusal it is important to first understand the nature of anxiety. Anxiety is another word for fear and is thought of as a response involving thoughts, behaviors, and physical responses. The thoughts that accompany anxiety have to do with anticipation of something terrible that is about to occur. For younger children they may be worried that something terrible may happen to their parents while they are at school. For children that are somewhat older they may anticipate something terrible happening to themselves while at school. A better understanding of school refusal occurs when we have a clear picture of the thoughts that occur when the anxiety or fear is highest. The physical reactions that occur with anxiety are what is commonly known as a “fight or flight” response. This includes a rapid heart beat, breathing changes, muscular tightness and sweating. The behavior that naturally accompanies this response is avoidance or in this case school refusal.
The early signs of childhood anxiety which can often result in school refusal include: a reluctance to fall asleep without being near parents, nightmares, extreme homesickness, as well as physical symptoms such as stomach pain and rapid heart-rate.
Family history and parenting style are extremely important components to school refusal. It is relatively easy for a parent to inadvertently strengthen a child’s anxiety by not gently requiring the child to overcome the distress and challenge their avoidance of school.
- Practical Tips for Handing School Refusal
- Initiate a consistent bedtime and daily awakening schedule for her two weeks before the first day of school.
- Replace summer evening TV watching with reading.
- Have breakfast together and then go to school regularly before the first day and walk to the classroom.
- Meet briefly with your daughters’ new teacher or some other helpful staff member a few days before the start of school (call ahead to schedule this). This is a good time for you to meet, and have your daughter get comfortable with, the school staff.
- Speak with your daughter about these experiences, help her challenge any negative thoughts or fears she may be having and tell her how confident you are in her ability to overcome stomachaches, headaches or other physical complaints she may have and assure her when she goes to school she will have fun and make friends.
If on the first days of school your daughter does become anxious and resistant it is very important that you stay calm and do not over-react. Your daughters’ Kindergarten teacher will have experience with this problem and will help your child settle in. It is important that you do not stay and wait for your daughter to calm down. Instead leave quickly and assure her you will be there to pick her up. Staying to long with your daughter may reinforce her anxiety and perpetuate the problem.
What to Do If the Situation Does Not Improve?
If these steps do not solve the problem within the first weeks of school your daughter could have a Separation Anxiety Disorder. Separation Anxiety Disorder affects approximately 4% of children (Anxiety Disorders Association of America). With Separation Anxiety Disorder, a child experiences excessive anxiety when away from home or separated from parents or caregivers. While separated, it is not uncommon for these children to have fears and worries regarding the health and safety of their parents.
Evidence suggests that cognitive behavioral therapy (CBT) is effective in the treatment of childhood anxiety disorders. If your daughter’s fears and worries continue your teacher or school psychologist may be able to refer you to a psychologist who specializes in cognitive behavioral therapy for children.
How Cognitive Behavioral Therapy Can Help
Anxiety disorders have been shown to be highly responsive to cognitive behavioral therapy. School refusal can be addressed with CBT anxiety protocols such as exposure and response prevention (ERP). ERP is a treatment method available for a variety of anxiety disorders. The intervention is based on the idea that a child/adolescent is exposed to their fears and through repetitive exposure they learn to overcome their avoidance. In doing so the thoughts/cognitions associated with the fear are altered and the fear and avoidance lessens and ultimately is extinguished.
Depression affects a significant portion of the population. This includes children and teens. In 2009, US News and World Report published an article which stated, “Serious depression afflicts two million teenagers each year”
Depressive disorders consist of a variety of symptoms in the areas of mood, thinking, behaviors and physical reactions. Mood related symptoms include sadness, irritability, depression and anger. Many depressed children and adolescents are also anxious and nervous. When children and adolescents are depressed their thinking may be characterized by negative thoughts about themselves (self criticism), negative thoughts about the future and negative interpretations/ thinking about ongoing events in their lives.
Cognitive therapy is a form of psychotherapy that has been demonstrated to be effective in the treatment of depression with children and adolescents. Cognitive therapy is an active, structured, directive form of therapy that focuses on the thoughts, beliefs and behaviors that accompany depressive disorders. In cognitive therapy, the child learns to identify, evaluate and change the thoughts, beliefs and behaviors that accompany depression. (In many cases parents are also instructed in how to help the child use CBT methods to combat their depression). CBT can lead to a significant reduction in depression symptoms – often in a brief period of time.
Other Childhood and Adolescent Disorders Related to Anxiety and Depression
Attention Deficit Hyperactivity Disorder (ADHD), Disruptive Behavior Disorders, Autism/Aspergers Disorders, Communication Disorders and Learning Disorders often co-exist with anxiety and depressive disorders in children and adolescents. Therefore our practice also includes a specialization in psycho-educational assessment for the purpose of diagnosis and treatment/intervention of learning and behavioral problems. Parents with concerns about their child’s cognitive processing (attention, memory, and perception), academic achievement, overall development, and psychological/social functioning are appropriate candidates for this type of assessment. These psycho educational assessments can provide important information to parents and educators about any special education needs that are appropriate for their child.