Anxiety

Cognitive Behaviour Therapy with Children and Young People

Paul Stallard

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317595793
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Cognitive behavioural therapy has proven to be an effective treatment for anxiety disorders in children and young people. This book provides an overview of CBT and explores how it can be used to help children with anxiety disorders.

In Anxiety: Cognitive Behaviour Therapy with Children and Young People Paul Stallard describes the nature and extent of anxiety problems that are suffered in childhood and discusses evidence for the effectiveness of the cognitive behavioural model as a method of treatment.

This concise and accessible book, written specifically for the clinician, provides a clear outline of how CBT can be used with children suffering from anxiety disorders in an easy to follow format. The book provides many ideas that can be incorporated into everyday practice, as well as clinical vignettes, case examples, and worksheets for use with the client.

This straightforward text will prove essential reading for professionals involved with children who have significant anxiety problems including mental health workers, social services staff and those working in educational settings.

The final chapter of this book contains worksheets that can be downloaded free of charge to purchasers of the print version. Please visit the website to find out more about this facility.

1

Anxiety problems in childhood

Anxiety disorders in children and young people are common and constitute the largest group of mental health problems during childhood. They can have a significant effect on everyday functioning, impact on developmental trajectories and interfere with educational attainment, the development of friendship and family relationships. Many anxiety disorders persist and, if left untreated, increase the likelihood of problems in adulthood.

The anxiety response is complex and involves cognitive, physiological and behavioural components (Weems and Stickle, 2005). The cognitive component involves appraising situations and events for anticipated risk; the physiological component prepares the body for any necessary action (e.g. flight or fight) while the behavioural component helps the child to anticipate and avoid future danger. Anxiety is a normative response designed to facilitate self-protection with the particular focus of the fear and worry varying according to the child’s development and previous experiences.

One of the important cognitive components of anxiety is that of worry, with community surveys indicating that worries among children are common. Muris et al. (1998) found that 70% of children aged 8–13 reported that they worried every now and then. The content of these worries focused on school performance, dying, health and social contacts, with the most intense worries occurring two to three times per week. Similar findings were reported by Silverman et al. (1995) who found that the three most common areas of worry related to school, health and personal harm.

Children with identified anxiety disorders referred to specialist clinics share similar concerns. Their main areas of worry relate to health issues, school, disasters and personal harm, with the most frequent worries being about friendships, classmates, school, health and performance (Weems et al., 2000). The difference between community and referred groups is not necessarily the specific content of the worries but it is their intensity (Perrin and Last, 1997; Weems et al., 2000). Comparisons between community and referred children found that clinically anxious children had more intense worries (Weems et al., 2000)

The specific focus of worries in children and young people changes across childhood. Weems and Stickle (2005) suggest that the symptoms of specific anxiety disorders are shaped by sequential developmental challenges in cognitive, behavioural and social processes. With young infants the key tasks are concerned with survival, so that fear and anxiety are related to sudden loud noises, unexpected events and a wariness of strangers. As the child develops an attachment to their primary caregivers a fear of separation emerges as common by the end of the first year. By the age of six children become more independent and begin to recognise their potential vulnerability, resulting in worries about the loss of or separation from parents continuing. In addition, specific fears such as those of animals and the dark emerge. Between the ages of 10 and 13 children become increasingly aware of their own vulnerability with fears about personal injury, death, danger and natural disasters emerging. By adolescence the nature of the fears is based more on social comparisons, and anxiety about failure, criticism, and physical appearance is common (Warren and Sroufe, 2004). Fears and worries during childhood are therefore normal but become problematic when they become persistent, severe and incapacitating, and interfere with or limit the child’s everyday life and functioning.

Worries in children are common and appear to be a normal part of child development.

Children with anxiety disorders tend to have more intense worries.

As children develop and their cognitive capacity increases, the focus of worries and fear shifts from concrete to more abstract concerns.

Prevalence

Point prevalence community surveys in the UK and the USA indicate that 2–4% of children aged 5–16 fulfil Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnostic criteria for a severe anxiety disorder with accompanying significant impairment (American Psychiatric Association (APA), 2000; Costello et al., 2003; Meltzer et al., 2003). In general, anxiety disorders tend to be more prevalent in girls than in boys, and in older children. In particular, girls are more likely than boys to report phobias, panic disorders, agoraphobia and separation anxiety disorder.

In terms of the nature and course of anxiety disorders, a great deal can be learned from longitudinal studies. In the USA, the Great Smoky Mountains Study recruited a random sample of 1,420 children aged 9, 11 and 13 and followed them up until the age of 16 (Costello et al., 2003). The three-month point prevalence of children fulfilling DSM-IV criteria for anxiety disorder varied from 0.5% at age 9/10 to 1.9% at age 11, 2.6% at 13 and 3.7% at 15, with the lowest rate being in 12-year-old children. In terms of specific disorders, separation anxiety decreased in prevalence with age whereas social anxiety and panic increased. Cumulative estimates suggest that by the age of 16, approximately 10% of children will have met DSM-IV criteria for an anxiety disorder.

Rates are significantly higher if the impairment criteria are omitted. For example, Costello et al. (1996) in the Great Smoky Mountains Study found that 20% of children suffered with an emotional disorder. A similar rate was found in a community survey of 1,035 children aged 12–17 in Germany, where estimated lifetime rates of anxiety disorders in adolescents were 18.6% (Essau et al., 2000).

In terms of specific disorders, Costello and Angold (1995) concluded that overanxious disorder, generalised anxiety disorder, separation anxiety and simple phobia “are nearly always the most commonly diagnosed anxiety disorder, occurring in around 5% of children while social phobia, agoraphobia, panic disorder, avoidant disorder and obsessive-compulsive disorder are rare, with prevalence rates generally well below 2%”.

Approximately 1 in 10 children and young people will fulfil diagnostic criteria for an anxiety disorder over the course of their childhood.

Co-morbidity

There is considerable co-morbidity between anxiety disorders and also with other emotional disorders, particularly depression (Costello et al., 2003; Essau et al., 2000; Greco and Morris, 2004; Newman et al., 1996). In view of this overlap, specific anxiety disorders may be confused. For example, with separation anxiety disorder the child may express a number of worries or fears that could be mistaken for generalised anxiety disorder. Similarly, the social avoidance that characterises social phobia could be confused with the apathy that is a common feature of depression.

The other co-morbid condition is that of alcohol misuse, whereby children with anxiety disorders are at an increased risk of alcohol misuse as adolescents. It has been hypothesised that alcohol may be used as a way of reducing or alleviating unpleasant anxiety symptoms (Schuckit and Hesselbrock, 1994).

Co-morbidity with other anxiety disorders and depression is common.

Course

Although results are not always consistent (Last et al., 1998), most longitudinal studies have demonstrated that many anxiety disorders in children persist into adulthood.

In New York, a sample of 776 children aged 9–18 who received psychiatric assessments were followed up two and nine years later (Pine et al., 1998). There was a strong association between adolescent anxiety and the presence of anxiety at each subsequent assessment. Anxiety and depressive disorders in adolescence led to a two- to three-fold increase in the risk of these disorders in young adulthood. There was some evidence of specificity, with simple and social phobias in adolescence predicting simple and social phobias in young adulthood. The relationship over time with other anxiety disorders such as generalised anxiety disorder, overanxious disorder and fearfulness was less strong. Nonetheless the data suggests that most anxiety disorders in young adulthood are preceded by anxiety disorders in adolescence.

In a longitudinal study in New Zealand, a birth cohort of 1,265 were assessed for anxiety disorders between the ages of 14 and 16 and then on a range of measures of mental health, educational and social functioning between the ages of 16 and 21 (Woodward and Fergusson, 2001). After controlling for possible confounding variables, significant associations were found between anxiety in adolescence and anxiety, depression, illicit drug dependence and educational underachievement in young adulthood.

Similar results were found in the Dunedin Multidisciplinary Health and Development Study in New Zealand (Kim-Cohen et al., 2003; Newman et al., 1996). A birth cohort of approximately 1,000 children was assessed at various times during childhood and into young adulthood at ages 18, 21 and 26. Of those with a diagnosed anxiety disorder at the age of 21, 80.5% had received a prior diagnosis before the age of 18. This figure was similar at age 26, where 76.6% of those with an anxiety disorder had received a prior diagnosis before the age of 18. This was relatively consistent across the specific disorders: generalised anxiety disorder (81.1%), panic disorder (78.9%), simple phobia (84.1%) and social phobia (72.8%).

Childhood anxiety can have an unremitting course and persists into adulthood.

Aetiology

There are multiple pathways to the development of anxiety disorders in children and adolescents that involve a complex interplay of biological, environmental and individual factors. This is based on the principles of multifinality (any single factor leads to multiple outcomes) and equifinality (many pathways may lead to the same outcome). A biological vulnerability (e.g. behavioural inhibition) is assumed to predispose the child to an anxiety disorder which is then activated and maintained by environmental factors (e.g. parental behaviour), cognitive processes (e.g. biased cognitions and processes) and learning experiences (e.g. conditioning and avoidance).

A biological vulnerability through genetics and temperament in the form of hypersensitivity to stress and challenge predisposes children to the development of anxiety disorders. This genetic influence has been investigated by examining the concordance of anxiety disorders within families. This has involved “top-down” (i.e. investigating the children of adults with anxiety disorders) and “bottom-up” (i.e. investigating adult relatives of children with anxiety disorders) approaches. Studies have consistently demonstrated high familiarity of anxiety disorders, with up to one-third of the variance being attributed to genetic influences.

Temperament is one of the constitutional constructs that has received considerable attention, and refers to a relatively stable way of responding to events across settings and time. The temperamental factor that has perhaps attracted most interest is that of behavioural inhibition: the tendency to exhibit fearfulness and withdrawal when confronted with novel or unfamiliar events or situations. The research suggests that behavioural inhibition, particularly when it remains stable over time, is associated with increased risk of subsequent anxiety disorders. However, while there is an important association between behavioural inhibition and anxiety, not all children with a predisposing temperamental vulnerability develop anxiety disorders. Environmental and individual specific factors also play a significant role in the aetiology and maintenance of anxiety disorders.

One of the most important environmental influences for children is the family. This provides the context within which anxious behaviour could be modelled and/or reinforced. Parental psychopathology may result in children being repeatedly exposed to anxious behaviour in which fearful behaviour and avoidance are modelled. These behaviours can also be reinforced through parenting practice where parents of anxious children encourage avoidant behaviours in their children. Similarly, a restrictive style of parenting characterised by parental over-control and over-protection limits the development of autonomy. In turn this increases dependency, restricts the opportunities available to children to develop problem-solving skills and increases the expectation that fearful events are unpredictable and uncontrollable.

Individual conditioning and observational learning experiences are also important and are particularly relevant to the aetiology of phobic disorders. These disorders can develop through different pathways in which identified events become conditioned with a terror or extreme fright response. This can occur through direct experience, by indirectly observing a phobic reaction in another or through the provision of information. However, while direct and vicarious conditioning experiences are important, it is not always possible to identify their occurrence, suggesting that once again other pathways are equally important in the development of fears and anxiety disorders.

Finally, cognitive processing is important in determining how children perceive and interpret their environment. Information-processing approaches have explored the way children select, attend to and interpret cues as dangerous or threatening. Anxious children are more likely to attend selectively to threat cues and perceive more threat in ambiguous situations.

There are many different pathways to the development of childhood anxiety disorders.

Genetic influences and temperamental factors are predisposing factors that can increase vulnerability.

Important environmental influences include familial factors, learning experiences and cognitive factors.

Types of anxiety disorder

Apart from separation anxiety disorder, the DSM-IV-TR (APA, 2000) does not have specific categories for childhood anxiety disorders. These are generally listed under “anxiety disorders” with some specific comments about the different way these might be manifest in children.

ICD-10 (World Health Organization, 1993) includes a specific section for emotional disorders with onset specific to childhood and includes separation anxiety disorder, phobic anxiety disorder and social anxiety disorder. The other common anxiety reactions displayed by children – social phobia, panic disorder and generalised anxiety disorder – are included within the general section describing neurotic, stress-related and somatoform disorders. While the onset...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• 1 Anxiety problems in childhood
• 2 Cognitive behaviour therapy
• 3 Dysfunctional cognitions and processes
• 4 Parental behaviour and childhood anxiety
• 5 Assessment and problem formulation
• 6 Psycho-education, goal-setting and problem formulations
• 7 Involving parents
• 8 Emotional recognition and management
• 9 Cognitive enhancement
• 10 Problem-solving, exposure and relapse prevention
• 11 Common problems
• 12 Materials and worksheets
• References
• Index