Frequently Asked Questions About Childhood Anxiety Disorders and Treatment
Diagnosing Anxiety Disorders
Q: What are anxiety disorders?
A: Anxiety disorders are mental health conditions characterized by worries and fears that are persistent and excessive. The worries are out of proportion to the stressor and/or may be inappropriate for the person’s developmental level. The majority of anxiety disorders require a duration of at least six months to be diagnosed. However, there are several anxiety disorders that may be diagnosed in a shorter amount of time, such as Separation Anxiety Disorder, Selective Mutism and Panic Disorder, which require a duration of at least one month to be diagnosed. Anxiety disorders not only cause high levels of distress, but also often result in impaired ability to perform in important areas of life, such as academically, interpersonally, hygienically, etc. (Please see our previous blog entry – Normal Anxiety Versus Clinical Anxiety: When Should You Seek Help – for further information).
Q: How common are childhood anxiety disorders?
A: Anxiety disorders are the most common occurring mental health conditions in youth. The Anxiety and Depression Association of America (ADAA) reports that anxiety disorders are experienced by one in eight children. According to the Child Mind Institute (2015), 80% of kids with clinical anxiety are not receiving treatment. Anxiety disorders are diagnosed approximately two times as often in females. There are no significant gender differences related to the age of onset in childhood anxiety disorders, except for Obsessive-Compulsive Disorder, which presents at earlier ages in males. If left untreated, the majority of youth will continue to meet the diagnostic criteria for anxiety disorders as they age, which is reflective of the need for early intervention.
Q: What are the types of anxiety disorders and obsessive-compulsive disorders seen in children?
A: Children are most commonly diagnosed with:
- Panic Disorder with or without Agoraphobia
- Panic disorder is characterized by recurrent and unexpected panic attacks with concerns of having future panic attacks and/or a significant change in behavior related to the panic attacks
- Panic attacks are characterized by a constellation of at least four symptoms (Please see our previous blog entry – The Deconstruction of a Panic Attack – for further information) that reach a peak within minutes
- Agoraphobia may occur alongside of panic disorder and creates difficulty with remaining in environments/situations that the person perceives would be being difficult to leave or escape. They fear that they may experience a panic attack and/or that help will be unavailable if they were to experience a panic attack
- Separation Anxiety Disorder
- Separation anxiety disorder is characterized by recurrent excessive fear or anxiety separating from attachment figures. The individual may experience anticipatory anxiety about being alone and report physical symptoms
- Specific Phobia
- Phobias are persistent fears that are out of proportion to the situation or anticipation of a future situation
- Avoidance is observed, despite the fact that the perceived danger is excessive or unreasonable
- Phobias may include (but are noted limited to) stimuli such as animals, storms, vomiting, needles, flying, etc.
- Selective Mutism
- Selective mutism is a consistent failure to speak in situations in which there is an expectation for verbal communication. The failure to speak is not better explained by a communication disorder or lack of comfort with the spoken language
- The failure to speak negatively impacts academic functioning and/or social communication
- Generalized Anxiety Disorder (GAD)
- GAD is characterized by excessive anxiety/worry about multiple different events or activities. The individual finds it hard to control the worry, experiences difficulty concentrating, complains or feeling fatigued and/or restless, is irritable, and endorses muscle tension and sleep problems
- The degree of worry causes clinically significant distress and/or impairments in important areas of functioning
- Social Anxiety Disorder
- Social anxiety disorder consists of an intense fear or anxiety associated with social situations in which the person may feel embarrassed, be judged or evaluated, and/or in which others may notice that they are anxious
- School Anxiety/School Refusal
- School refusal is a behavioral symptom of anxiety in which there is resistance to attending parts or all of the school day (Please see our previous blog entry –School Anxiety/School Refusal: What Is It and How Is It Treated? – for further information)
- It can occur alongside of a variety of mental health conditions, learning problems, and/or medical issues
- Trichotillomania is characterized by a recurrent pulling of one’s hair, resulting in hair loss. Hair pulling may occur anywhere on the body, but most often occurs from the scalp
- There may be repeated attempts to decrease or discontinue skin picking
- Depending upon the age and self-awareness of the child, the hair pulling may cause distress and/or impairment in important areas of functioning
- Please see our previous blog entry – Trichotillomania– for further information
- Excoriation Disorder
- Excoriation Disorder is characterized by recurrent skin picking that results in lesions
- There may be repeated attempts to decrease or discontinue skin picking
- Depending upon the age and self-awareness of the child, the skin picking may cause distress and/or impairment in important areas of functioning
- Obsessive-Compulsive Disorder (OCD)
- OCD is characterized by persistent and recurrent thoughts, images, and/or impulses that are experienced as intrusive or unwanted (Please see our previous blog entry – Intrusive Thoughts – for further information).
- In response to obsessions, the individual responds with repetitive and deliberate behaviors (compulsions) and/or mental acts that are performed with the intention to neutralize the obsessions. Compulsions take up minimally one hour of time per day
- Please see our previous blog entries on the subtypes of OCD for further information
Etiology of Anxiety Disorders
Q: What sort of factors contribute to the development of childhood anxiety disorders?
A: While there are a number of interrelated causes associated with the development of an anxiety disorder, the etiology of these conditions differs from person to person. Common factors that contribute to the development of anxiety disorders in children include (Raggi, et al., 2018):
- High levels of negative reactions to stress
- Individuals who tend to respond to stressors with high levels of anger, fear, sadness, frustration, etc. are more likely to report clinically significant anxiety and be more reactive to stress. They tend to experience negative feelings more often and tend to feel triggered more easily than peers with lower levels of reactivity to stressors
- Over-focusing and negative interpretations
- When we encounter something stressful, our attention zeros in on this trigger as we assess it and decide whether or not it is something that could be harmful to us
- Hyperfocusing on a stressful/anxiety-provoking stimulus can amplify the trigger’s perceived threat, which leads the person to interpret the trigger as dangerous or scary
- Often, neutral stimuli become perceived as scary or threating and the individual may anticipate a high likelihood that something may go wrong, which often leads to engagement in avoidance behaviors (Please see our previous blog entry – Understanding the Cycle of Anxiety– for further information).
- Anxiety sensitivity
- Due to the intensity of the experience of feeling anxious, children are often worried about feeling anxious in the future. This “anxiety about having anxiety” will often lead them to avoid situations that they believe may trigger such feelings
- Inability to tolerate uncertainty
- Children often exhibit a great deal of distress and agitation in situations that are uncertain or ambiguous, which may result avoiding uncertain situations
- Genetics and home environment
- Children who have relatives who struggle with anxiety disorders are at an increased risk of developing an anxiety disorder themselves, particularly if it is a first-degree relative living in the same home
- Parenting style and/or parental modeling of anxious behaviors
- Research has revealed that certain types of parenting/parent-child interaction styles have been linked to increased risk of anxiety disorders in children. Styles include critical or controlling parent styles and low expression of warmth or low ability to soothe children
- Adverse life experiences and the perception of having low control
- Feeling as though we have minimal control over stressful situations typically exacerbates anxiety levels. Experiences that may lead to an increased risk for developing an anxiety disorder include dealing with a chronic illness (their own or a family member’s), being bullied, disruptions in the family unit, uncertainty about what to expect at home, etc.
Q: What maintains childhood anxiety disorders?
A: Factors involved in the maintenance of anxiety disorders include (Raggi, et al., 2018):
- Physiological responses
- Physical symptoms of anxiety often increase the emotional experience of anxiety. Common physiological responses associated with anxiety include increased heart rate, sweating, erratic breathing, dizziness, abdominal distress, etc.
- These responses may increase feelings of anxiety and feeling out of control, which leads to an increased likelihood of having more anxious thoughts (since the system is already primed in this heightened state)
- Thought processes
- Research has tied certain patterns of thought to the experience of anxiety, including cognitive distortions, overestimating the likelihood and severity of experiencing negative outcomes, holding low expectations for one’s ability to cope with stressors, having a low tolerance for uncertainty, etc.
- Behavioral responses
- Research has also demonstrated that certain ways of responding can maintain the anxiety cycle. Responses that are associated with preserving the anxiety cycle include avoidance, reassurance seeking, engaging in safety behaviors/compulsions/rituals, receiving accommodations from others, etc.
- In the short-term, such responses reduce the experience of anxiety, but only temporarily. In the long-term, they strengthen the intensity of the anxiety response by creating an increased reliance on maladaptive coping strategies (Please see our previous blog entry – Understanding the Cycle of Anxiety– for further information).
Treatment will target each of these domains in order to address the multi-pronged experience of anxiety. The good news is that because these domains are highly interrelated, if any one of the domains is targeted, an effect will also be enacted on the other domains.
Treatment for Anxiety Disorders in Children
Q: How do you treat childhood anxiety disorders?
A: Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) are the gold standard treatments for anxiety disorders used by child therapists. The overarching aim of treatment is to target and weaken the connection between the factors that have been maintaining anxiety (overestimation of threat and the various forms of avoidance). Treatment for childhood anxiety disorders typically includes:
- It is important that both parents and children understand the nature of anxiety and the rationale for treatment. Treatment should take a teamwork approach to support children in combatting their anxiety
- Building effective coping strategies
- Learning new coping strategies that empower children to face their anxiety is an essential component of the treatment process. Since there is an inverse relationship between anxiety and confidence, building coping skills will enable children to feel more confident in facing their fears and working towards achieving treatment goals
- Cognitive restructuring
- Cognitive restructuring is meant to help children change their thinking patterns to make them more balanced and less likely to trigger/exacerbate anxiety. It will also help them to talk back to anxious thoughts and motivate themselves through challenging situations. Cognitive restructuring helps children to increase their ability to think constructively and to approach their anxiety triggers, rather than avoiding them
- Parent training
- Parents have a critical role to play in the treatment of childhood anxiety
- Parental involvement is predictive of better treatment outcomes as parents can help their children to learn the skills to manage anxiety and practice them outside of therapy to expedite the process of achieving positive gains
- Utilization of a rewards system
- A rewards system is mean to motivate and/or incentive children to engage in challenging their anxiety
- Specific goals must be identified and linked to specific amounts of points/tokens, which can later be exchanged for a reward corresponding to the number of points earned. Points can be earned for:
- Daily rewards, such as 10 minutes of extra screen time
- Weekly rewards, such as going out for ice cream
- Big rewards, such as having a sleepover with friends
- Exposure and Response Prevention (ERP)
- Exposure is a behavioral intervention whereby children gradually, intentionally, and repeatedly encounter aspects of anxiety-provoking stimuli in order to challenge their anxiety. Exposure is done in a systematic way so that once anxiety diminishes and the child habituates, the fear response to that particular stimulus is weakened or extinguished (Please see our previous blog entry – What is Exposure and Response Prevention (ERP) – for further information).
- Response prevention refers to the inhibition of using a safety behavior, compulsion, or ritual to deal with an anxiety trigger. Response prevention is a necessary element of ERP treatment is implemented to help children learn how to work through anxious situations without avoiding or engaging in other behaviors that will preserve the fear
Parental Roles in Anxiety Treatment
Q: How are parents involved in the treatment process?
A: Depending upon the age of the child, parents may complete the intake process without their child present, or they may provide collateral information to their child’s account during the intake. During the diagnostic intake, information is collected about the child’s symptoms, functional areas that are being impacted, underlying fears associated with their anxiety, and background information (e.g. medical history, family history, academic history, etc.). Often, a separate parent appointment is conducted early in the treatment process to reinforce psychoeducation and answer parents’ questions about their role in treatment and how they can be most helpful. Parents are instrumental in the construction of the ERP hierarchy, which will serve as the roadmap for treatment. Once exposures begin, parents will be present to observe how the child therapist structures and implements an exposure. It is critical that parents are a part of the ERP process as they will help their child practice exposures in between sessions. Over time, the child therapist will begin to fade out their instructions to ensure that parents and patients are well-versed in designing and implementing exposures, as needed.
Q: What can I do in the moment to help my child when he/she is feeling anxious?
A: First, it is important to remain calm and neutral when your child’s anxiety is coming to the surface. Children are very attuned to their parents’ reactions and if they see their parents becoming activated, this will only increase their own anxiety. If parents can model a calm response, the child’s anxiety will not typically intensify, and it will be more likely to decrease at a faster rate. Validate your child’s experience without trying to change it. Supplying all the answers and fixing the problems are not helpful things to do in the long run. In fact, these methods are counterproductive. Parents should instead redirect their child to use his/her coping skills (perhaps have a ready-made list of coping strategies on hand) and provide praise and encouragement for all efforts made.
Q: What does symptom accommodation look like?
A: When your child is in the throes of anxiety, it can be very difficult for parents to witness without trying to reduce their distress and/or remedy the situation. These are good parenting instincts! However, in their desperation to help, parents may actually be unintentionally doing things that either pacify anxiety temporarily and/or maintain the anxiety in the long run. Symptom accommodation may look like:
- Giving into your child’s demands (e.g. opening doors for them so they do not need to touch the handles)
- Providing reassurance to your child (e.g. answering the same question or variations of the same question repeatedly)
- Decreasing your child’s responsibilities (e.g. allowing them exempt from chores)
- Avoiding certain topics of discussion (e.g. not talking about upcoming vacation)
- Protecting/rescuing your child from consequences (e.g. protesting a bad grade for work that was not submitted at school)
- Following certain routines to minimize anxiety (e.g. following an elaborate bedtime routine so that nothing “bad” will happen during the night)
One component of parent training is to help parents channel their desire to help into constructive means, which will help their children to work through their anxieties, rather than work around them.
Q: What is the difference between reassurance and encouragement?
A: Reassurance strengthens the anxiety over time by increasing the child’s reliance on others in order to feel okay. Anxiety is maintained by doubt. Thus, if we have to rely on what others say in order to feel less anxious, this does nothing to dispel the doubt that we have about our ability to manage the situation on our own. Reassurance might sound like: “There’s nothing to worry about today. I’m sure it will be fine.” No one can promise that this reassurance is actually true. Encouragement, on the other hand, strengthens the child and provides support for them to cope with difficult feelings and situations. Encouragement validates the struggle: “I understand that your anxiety is making you feel uncomfortable, but I know you are brave and that you can try to work through it.” Encouragement also acknowledges the efforts: “I am so proud of you for attempting to get closer to the dog today. You were scared, but you did it anyway. Way to go!”
Q: What instructions do you have for parents who are helping their children complete ERP homework?
A: The general rule with ERP is the more often you practice the exposure, the faster it will become easier and/or you will learn that you can tolerate the stress. A significant amount of progress can be made by diligently completing therapy homework in between sessions. Completing the homework will help to expedite the achievement of gains, facilitate the generalization of progress to other environments (we want gains to extend beyond the therapy office and into the areas where they are most needed: at home, school, with friends, etc.), and help the child to become more adept at handling spontaneous situations that provoke anxiety. Assigned therapy homework is essentially the psychotherapy version of a prescription, and it is essential that parents ensure that it is being completed as instructed. Before engaging in at-home exposures, parents will have observed the child therapist conducting the exposure during sessions. This modeling should serve as a template for at-home practice. ERP homework should be completed every day. It is important to minimize distractions and therefore devices, siblings, pets, etc. should not be in the area where exposure is being conducted (unless they are directly involved in the exposure). Parents must refrain from providing reassurance during the course of the exposure and should be prepared to undo a compulsion or other form of avoidance (e.g. not allowing the child to use his/her sleeve to open a door). It is of great importance that parents do not prematurely terminate the exposure when distress increases. Exposures are meant to provoke anxiety, this is normal. Once the peak or burst of anxiety is experienced, it should decline. If the exposure is ended too abruptly, the child is left with the impression that the exposure was too scary or challenging and they will not only feel distressed and discouraged, but they will also be more hesitant to try again in the future. Remember, the exposure was first completed during session so the child therapist has determined that your child can handle it. Encourage them to stick with it (ex: “I know anxiety is tough, but you are stronger!”) Exposure work should be concluded at least two hours prior to going to bed so as to not interfere with sleep. Lastly, it is important to track exposure practice so that there is data logged on daily progression.
Q: What if the anxiety comes back after they finish treatment?
A: It is important to remember that anxiety is an emotion that everyone experiences, whether or not their anxiety meets diagnostic criteria for an official psychiatric diagnosis. Anxiety becomes a cause for concern when it is persistent, outside the scope of what most children in that age group and situation would experience, and negatively impacts functioning and quality of life. Treatment is conducted in such a way that children and their parents become skilled in devising and implementing their own exposures. In other words, the knowledge and tools gained in treatment can be reapplied as often as needed. Therapy is not complete until patients and their families are able to successfully use their strategies. As therapy ends, the child therapist works with patients and their families to develop a relapse prevention plan, whereby they anticipate the types of triggers that may come up and identify how to effectively respond to them. Booster sessions are also offered to fine-tune any skills that need reinforcement and/or to address any new issues that may arise. There may be some periods in which anxiety is more heightened and patients and their families may experience a lapse before putting their skills back into practice. While it is important to maintain the strategies learned in therapy, it is normal to experience ebbs and flows with anxiety. It is important to remember that the comeback is always more important than the setback and that professional help is always available.
Working closely with a child therapist at The OCD & Anxiety Center in Oak Brook and Orland Park, IL can help to manage various types of anxiety disorders that present in children. Effective mental health care is instrumental to not only improving health and overall well-being, but also enhancing functioning in important life areas, such as academic functioning and social engagement. To begin working with a child therapist, please contact our office at (630) 522-3124 and schedule your child’s first appointment with one of our anxiety experts.