Treating Childhood and Adolescent Anxiety

A Guide for Caregivers

Eli R. Lebowitz, Haim Omer

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118238028
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

"Lebowitz and Omer have taken the latest and most relevant scientific research and synthesized it into an essential read for caregivers of anxious children. Treating Childhood and Adolescent Anxiety: A Guide for Caregivers provides an 'inside look' at the nuts and bolts of cognitive behavioral therapy (CBT) for childhood anxiety—the treatment of choice among leading researchers and experts. The book is filled with analogies, examples, and practical advice that professionals and parents will refer back to over and over again."
—Candice A. Alfano, PhD; Director, Sleep and Anxiety Center for Kids (SACK) Associate Professor, Department of Psychology, University of Houston

PRACTICAL REAL-LIFE SOLUTIONS FOR CHILDREN LIVING WITH ANXIETY

FOCUSING ON THE SPECIAL ROLE OF THE CAREGIVER IN ACHIEVING SUCCESSFUL TREATMENT

Focusing on the treatment of childhood anxiety, both in one-on-one therapist to child treatment and within the family, Treating Childhood and Adolescent Anxiety: A Guide for Caregivers adopts an integrated approach presenting novel strategies to help mental health professionals and families create change and momentum in otherwise stagnant situations.

This empowering guide offers practical, evidence-based, and theory-driven strategies for helping children to overcome anxiety, even if they resist treatment. Uniquely providing concrete advice for both the therapeutic and home environment, this insightful book covers:

• What to do when anxiety takes over the family
• School phobia and school refusal
• Working with highly dependent young adults
• Parental support and protection
• Creating and maintaining family boundaries
• A walk-through of The Supportive Parenting for Anxious Childhood Emotions (SPACE) Program
• Cognitive, behavioral, physiological, and emotion-based tools for treating anxiety
• Medication for childhood anxiety

Part One

Introduction

Chapter One

Anxiety Disorders of Children and Adolescents

Anxiety disorders are common in children and adolescents and can impact many aspects of healthy functioning and development. Anxiety disorders in children also impact parents and family.

Key points in this chapter:

• The prevalence and course of anxiety disorders.
• The different anxiety disorders and the criteria for their diagnosis.
• The impact these disorders can have on the child and the family.
• The role of primary care providers.

Common Anxiety Disorders of Childhood and Adolescence

Anxiety disorders are the most frequent disorders of childhood, and likely of adulthood as well (Kessler, Chiu, Demler, & Walters, 2005). Lifetime and point prevalence estimates of their occurrence range quite widely, with the lowest estimates indicating a rate of around 3% for at least one anxiety disorder at any given time and the highest estimates indicating that upward of 30% (Costello, Egger, & Angold; Merikangas et al., 2010) of people will suffer from an anxiety disorder at some point in their lives. The differences in estimates reported likely stem from the different populations studied, the different tools used for screening and assessment, the variability in criteria and procedures for establishing diagnoses (for instance, child only versus child or parent report), the quality of sampling in different studies, and other methodological variables. In any event, there can be little doubt that anxiety disorders are common among children.

Suffering from anxiety can have a devastating and widespread impact on a child and on the family. Anxiety disorders tend to be chronic (Keller et al., 1992), rarely “just going away” on their own with spontaneous remission in only a minority of cases. But the impact of the anxiety extends beyond the specific criteria used for establishing a diagnosis (Angold et al., 1998). Physical and mental health, social functioning, academic achievement, family relationships, and overall quality of life can all be negatively affected by anxiety (Woodward & Fergusson, 2001).

The current version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) (American Psychiatric Association, 2000) recognizes the existence of a number of discrete patterns of anxiety-related symptoms and this is to be the case in the upcoming DSM-V as well, despite some changes (e.g., excluding obsessive-compulsive disorder from the anxiety disorders group). In this book, however, we have chosen to discuss the anxiety disorders as a group, including OCD, for a number of reasons.

First, the categorization of anxiety disorders into separate entities relies primarily on identifying different stimuli or situations that provoke the anxiety and classifying the disorder accordingly. For example, those who respond with anxiety to social situations are likely to meet criteria for social phobia whereas children who have a fear of separation from their parents would better be described as having separation anxiety disorder. Although such a classification serves a number of important purposes, such as comparing the prevalence or treatment responsiveness of particular patterns of fear, it also creates a certain illusion—the idea that the problem is actually closely tied to the particular stimulus the individual fears. In this book we take the approach that anxiety disorders are more closely connected to how a child manages fear and the experience of anxiety than it is to the specific things that trigger the anxiety.

Additionally, the high rates of comorbidity between anxiety disorders support the idea that an underlying difficulty in regulating anxiety is a helpful way of conceptualizing the problem. Clinical experience, epidemiological studies, and the multitude of clinical samples reported on in papers about anxiety point to the conclusion that having one anxiety disorder is a powerful predictor of actually meeting criteria for at least one more (Rapee, Schniering, & Hudson, 2009). Both longitudinal and retrospective studies show that although anxiety tends to be chronic within disorders, having one anxiety disorder today also predicts having another different one in the future (Bittner, 2007). Although the theoretical implications of the high rates of comorbidity are equivocal (see Curry, March, & Hervey, 2004), they support considering all the subcategories of anxiety as a group.

Another reason for treating anxiety disorders as a group rather than as separate entities is the similarity in proven effective treatments. Using the statistical methodology of analysis of variance as a metaphor, one might say that the within group differences in treating anxiety are rather more pronounced than between group differences. In other words, treating a child or adolescent with anxiety is similar across disorders, although it may vary significantly between specific children. Two children suffering from social phobia might be no more similar in the course of therapy than a child with social phobia and one with a specific phobia, although some details of the treatment will naturally vary.

Finally, much of the work with anxious children requires addressing the whole family’s needs and roles. Parents of anxious children are faced with similar dilemmas, challenges, and questions although their children may experience the fear in different situations (Lebowitz, Woolston, et al., 2012). The questions that are raised by parents, such as “Should I give in or demand that he does it?”; “When is accommodation a good thing and when is it a problem?”; or “Is this a serious problem or simply attention-seeking behavior?” cut across the spectrum of anxiety disorders, ignoring nosological categories.

The following section describes the different anxiety disorders diagnosable under DSM-IV-TR and the way they affect the child and family. Later chapters focus on individual and family models and treatment strategies that can be applied across the range of disorders. Though there are many specific manuals for various disorders, and new ones are likely to appear, here we draw from the best-known techniques to date to help clinicians, parents, and children facing any of these disorders.

Separation Anxiety Disorder

This is the only anxiety disorder still classified in DSM-IV as a disorder of childhood, indicating the acknowledgment that anxiety is generally quite similar in its manifestations at different ages, although specific criteria can vary for diagnosing children in other disorders as well. Indeed, in the upcoming DSM-V, separation anxiety disorder is to be moved from the section on disorders of childhood and placed with all other anxiety disorders.

Separation anxiety is characterized by a child’s fear of separation from the home or caretakers. Children with separation anxiety usually worry about bad things that could happen to them or to their parents during times of separation. For example, children might fear being kidnapped or getting hurt when a parent is not there to help them. Children who worry about things that could happen to their parents might imagine them getting into a car accident or some such disaster. For some children the fear will be that the parents might simply disappear and never return, and they might spend time fantasizing about being reunited with their parents, even during minor separations.

Children with separation anxiety will often object to or try to avoid even small periods of separation, and some might strive to maintain direct contact with parents whenever possible. Many children with separation anxiety will even follow their parents from room to room around the house. A special focus for many children with separation anxiety is bedtime, when they may feel afraid of being left alone in their room and prefer to sleep next to a parent, either in their own bed or in the parents’. Some children will report having nightmares in which they are separated from their parents. Another night-related separation fear is that of being awake after parents are asleep. Many children try to avoid this either by going to bed first or by demanding that their parents stay up until they are asleep.

Many children will exhibit manifest anxiety by begging not to be left alone, clinging to a parent’s legs or even trying to block the door of the house when parents want to leave. Some might repeatedly try to make contact with the parents during times of separation, for example, by phoning them endlessly through the day. A major concern for some children with separation anxiety is the separation caused by the need to go to school and school avoidance is a common outcome of the fear. Others may go to school but find it hard to focus on classwork because of their persistent worrying.

Not surprisingly, separation anxiety is most common in younger children and tends to decrease in prevalence as children enter and pass through adolescence, although separation anxiety in young adults is also encountered. When a child with separation anxiety is absent from school for extended periods of time, the likelihood that they will continue to suffer from the disorder in adulthood increases. Early onset is specified in the diagnosis if the disorder appears before age 6, but the natural tendency of young children to proximity with their parents must be taken into account.

Separation anxiety has the clear potential to disrupt both the child’s individual functioning; for example, by limiting school attendance and performance or by curtailing social activities (e.g., avoiding sleepovers or visits to peers), as well as family functioning. Siblings may find themselves accommodating the child’s anxiety; for example, by spending less time with parents because of their need to be with the anxious child. Parents often adapt to the child’s anxiety by limiting their own departures from the home, returning earlier than they otherwise would from work, or sleeping alongside the child.

Panic Disorder and Agoraphobia

Panic attacks are brief periods of time during which a child, despite the absence of immediate danger, experiences intense anxious arousal. The panic attack can be primarily physiological in nature, including symptoms such as sweating, racing heart, shortness of breath, trembling, chest pain, or feelings of choking. In other cases the panic attacks have a more cognitive focus, including terrifying thoughts about losing control or going crazy, fear of dying, or feeling like reality has “shifted” (derealization), or that they have become detached from themselves (depersonalization). For many children the attack includes both cognitive and physiological symptoms.

Panic disorder is characterized by the presence of repeated panic attacks and a persistent worry about the possibility of having more such attacks in the future. Although the attacks themselves are brief, typically peaking within 10 or 15 minutes and even though some children experience only few actual attacks, they can be severely impaired by the fear of the experience being repeated. In addition, many children suffering from panic disorder report having frequent physical signs of anxiety that do not reach the level of a panic attack but cause discomfort or make them worry that an attack is imminent. This may be due to a tendency to constantly monitor their own inner physiological state (Schmidt, Lerew, & Trakowski, 1997), leading them to focus on transient normal changes that would otherwise not receive any attention.

Another theory proposes that the symptoms of panic are caused by an unnecessary triggering of the body system usually active during potential suffocation, as happens during overexposure to carbon dioxide (Klein, 1993). Children who have panic disorder may also interpret normal physical discomfort such as a headache or stomachache as the sign of something catastrophic, such as a life-threatening illness. This kind of monitoring and misinterpretation can lead to a vicious cycle in which focusing on their body causes them to recognize any changes, which in turn heightens anxiety. This can lead to a panic attack and causes even more inner focus and monitoring. Children may ask their parents to check their pulse, listen to their hearts, or provide reassurance that they are well. A related fear in children exists when a child is very afraid of vomiting and begins to focus on internal gastrointestinal signs, searching for clues of impending need to vomit (although this would be diagnosed as a specific phobia rather than panic disorder).

In many cases panic disorder will be associated with agoraphobia, which describes the fear or avoidance of situations in which they think they may experience symptoms of panic. A child who has had a panic attack in school, for example, may be afraid to go to school because of a fear of having another panic attack while there. In severe cases the avoidance will be generalized to any place outside of the home and the child may refuse to go out at all or need to be accompanied by a parent who can “rescue” them should an attack begin. This pattern increases the potential of even few and brief panic attacks to severely impair a child’s well-being and development for lengthy periods of time.

Panic disorder and agoraphobia are more common in adolescents than in children and only a relatively small number of cases are reported in younger children. The diagnosis, however, relies on the existence of at least two episodes that meet criteria for a full-blown panic attack, including at least 4 of the 13 possible symptoms listed by the DSM-IV-TR. Episodes including less than four such symptoms (dubbed limited-symptom attacks) may be significantly more common in the younger population.

The effect of panic disorder and agoraphobia on the family’s and parents’ functioning is caused by the need to provide reassurance to a child or even to arrange for repeated medical examinations. These may serve to alleviate parental worry about the child’s health but can also be triggered by the child’s need of professional medical confirmation that he or she is not at risk. The dramatic manifestation of anxiety, accompanied by terrible thoughts and extreme physical agitation, can cause parents to panic and be overwhelmed by their own fear for the child’s health. Parents are often much at a loss regarding how to respond to a child during an attack. The child, seeing how upset and worried the parents are, may take this as confirmation that something is indeed terribly wrong. Agoraphobia can impact the family by limiting the child’s ability to function independently, requiring parental accompaniment to locations and activities that would otherwise be done without them.

Specific Phobia

Specific phobias are fears of particular things or situations that cause a child to avoid contact with the feared stimulus or to be distressed when contact must be endured. There is no real limit on the objects that can become the focus of a child’s phobia but some common groups of phobias include fear of animals such as snakes, bugs, dogs, or bats; fear of natural phenomena including heights, darkness, storms, and water; fear of blood, injections, and medical procedures; and fears relating to particular situations such as riding in a car, plane, or elevator or of being in closed places. Other common fears in childhood include the fears of clowns, loud noises, or the things that make them such as balloons and the fear of throwing up. Some children will explain their fear as relating to a thought of harm that might come to them through exposure to the phobic object. For example, children might think they would be bitten if they were to approach a dog. Other children will have a fear of their own reaction to the stimulus. For example, the level of horror and revulsion that many children experience when confronted by a spider can be enough to cause the phobia even if they do not believe the spider is dangerous.

Although adults must recognize that their fear is irrational and extreme in order for the diagnosis to be conferred, this requirement does not exist for children. Many children, however, do display this kind of insight and acknowledge that the degree of fear or avoidance is not warranted by the realistic risk. Having insight can facilitate treatment of the phobia as children are more likely to engage in a process meant to reduce the fear if they realize it is not actually protecting them from harm.

Children with phobias will try to avoid any exposure to the feared stimulus. Often they will generalize the fear and avoidance to a wide array of situations, beyond direct contact with the object of their fear. For example, a child with a fear of dogs may be afraid to walk down entire streets because of a fear of seeing a dog or hearing one bark. Or the child might attempt to avoid any contact with pictures, toys, or stories that involve dogs. This pattern of generalization can cause the phobia to have a much wider impact on a child’s functioning than might otherwise have been expected. A child with a phobia of sharks might never encounter a shark but be terrified at any...

Table of contents

• Cover
• Table of Contents
• Title
• Copyright
• Dedication
• Preface
• Part One: Introduction
• Part Two: Working with the Anxious Child
• Part Three: Working with Parents
• Part Four: Ancillary Issues
• Appendix One: Family Accommodation Scale – Anxiety (FASA)
• Appendix Two: Coercive Disruptive Behavior Scale for Pediatric OCD
• Author Index
• Subject Index