Handbook of Childhood Behavioral Issues

Evidence-Based Approaches to Prevention and Treatment

Thomas P. Gullotta, Gary M. Blau, Thomas P. Gullotta, Gary M. Blau

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138860230
• eBook ISBN: 9781317507512
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

This handbook highlights present-day information and evidence-based knowledge in the field of children's behavioral health to enable practitioners, families, and others to choose and implement one of many intervention approaches provided. Using a standardized format, best practices for the prevention and treatment of many childhood behavioral disorders are identified based on current research, sound theory, and behavioral trial studies. This revision includes an integration of the DSM-5 diagnostic manual and new chapters on childhood psychosis and military families, and a thorough updating of the research in the previous edition.

Section III

Behavioral Health Issues

13
Anxiety Disorders in Childhood

Patricia A. Graczyk, Meghann M. Hennelly, and Sucheta D. Connolly

Anxiety disorders represent the most common form of psychopathology in children, with lifetime prevalence rates estimated at 15–20% (Beesdo, Knappe, & Pine, 2009). Anxiety disorders can significantly interfere with children’s functioning in school and in interpersonal relationships (Ezpeleta, Keeler, Erklani, Costello, & Angold, 2001), yet often go unrecognized by parents, primary care physicians, and school personnel.

Depression, disruptive behavior disorders, and other anxiety disorders often co-occur with an anxiety disorder (Ford, Goodman, & Meltzer, 2003). Childhood anxiety disorders also increase the risk for subsequent anxiety disorders, major depressive disorder, substance abuse, suicide, and psychiatric hospitalization in adolescence and young adulthood (Kim-Cohen et al., 2003; Schuckit & Hesselbrock, 1994). Indeed, given the increased risk for subsequent negative outcomes, anxiety could be considered a “gateway disorder” (Rapee, 2015).

Fortunately, exciting developments have occurred within the field of childhood anxiety disorders even since the publication of our chapter in the first edition of this book (Graczyk & Connolly, 2008). In the latest version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013), Selective Mutism (SM) and Separation Anxiety Disorder (SAD) are now included under the category of anxiety disorders. Current research questions related to cognitive-behavioral therapy (CBT), a well-established treatment for childhood anxiety, have shifted focus from determining whether CBT works to investigating how to tailor or augment CBT to address more intransigent forms of anxiety disorders and improve treatment accessibility. Greater emphasis also has been placed on addressing the needs of anxious preschoolers. Finally, promising alternative treatments are being developed that expand the repertoire of interventions to prevent and treat childhood anxiety.

In this chapter, we focus on children between the ages of 2 and 12. We start by providing an overview of the major anxiety disorders of childhood. We then discuss risk and protective factors associated with childhood anxiety. This discussion serves as a springboard for our review of treatment and preventative approaches. This chapter concludes with recommendations for best practices in the treatment and prevention of childhood anxiety disorders.

DSM-5 Anxiety Disorders and Incidence/Prevalence Rates

The DSM-5 (APA, 2013) provides a comprehensive categorical system for classifying anxiety disorders. Each anxiety disorder has distinct features, but all are characterized by excessive, irrational fear that significantly interferes with a child’s daily functioning. A brief synopsis of each major anxiety disorder of childhood follows.

Selective Mutism (SM) is characterized by an inability to speak in certain social situations such as school while speaking well in others such as with family members. Although relatively rare, with point prevalence rates of 0.03% to 1% (APA, 2013), SM can significantly interfere with a child’s functioning and be difficult to treat.

Children with Separation Anxiety Disorder (SAD) experience developmentally excessive fear and distress concerning separation from home or significant attachment figures. They often worry excessively about their parents’ health and safety, have difficulty sleeping without their parents, complain of stomachaches and headaches, and may manifest school refusal behaviors. Six- to 12-month childhood prevalence is estimated at 4% with lifetime prevalence at 7.8% by early adolescence (APA, 2013; Beesdo-Baum & Knappe, 2012).

Specific Phobia (SP) represents an intense fear of a particular object or situation and frequently is accompanied by avoidance of it. Compared to normal or developmentally appropriate fears, phobias are excessive and impairing. Prevalence in children is estimated at 5% with lifetime prevalence rates as high as 21% by early adolescence (APA, 2013; Beesdo-Baum & Knappe, 2012).

Generalized Anxiety Disorder (GAD) is characterized by chronic, excessive, and uncontrollable worry. Worries may relate to friends, family, health, safety, and/or the future. At least one somatic symptom is present such as motor tension or restlessness. The overall lifetime prevalence rate by early adolescence is estimated at 1% (Beesdo-Baum & Knappe, 2012).

Children with Social Phobia (SocP) (i.e., Social Anxiety Disorder) experience excessive fear or discomfort in social or performance situations. They anticipate negative evaluations from others and worry about doing something embarrassing in settings such as classrooms, restaurants, or sports activities. In children with SocP, behaviors could include tantrums, clinginess, crying, freezing, or an inability to speak in some situations. For children and young adolescents, the 12-month prevalence rate is estimated at 7% and the lifetime prevalence rate by early adolescence at 8% (APA, 2013; Beesdo-Baum & Knappe, 2012).

Panic Disorder (PD) involves recurrent and spontaneous attacks of intense fear accompanied by at least four somatic symptoms such as sweating, shaking, breathing difficulties, or rapid heart rate. PD is very rare in childhood, with prevalence rates estimated at less than 1% (APA, 2013).

Children with Agoraphobia (Ag) avoid or are extremely uncomfortable in places they fear they will be unable to get help or escape. Ag may present independently or accompany PD. Common stressful situations include crowds, enclosed places, open spaces, and travel away from home. Ag occurs very rarely in childhood.

The typical age of onset varies across the anxiety disorders and approximates the developmental progression of normal fears in childhood. SM often presents at ages 3–5, SAD at ages 6–9, GAD at any age but most often at ages 10–12, and Soc P at ages 12 and older (Albano & Kendall, 2002; Cunningham, McHolm, Boyle, & Patel, 2004). PD with or without Ag typically begins during late adolescence and young adulthood (APA, 2013).

Risk and Protective Factors Associated with Anxiety Disorders

Risk factors place children at increased risk of developing an anxiety disorder. Protective factors enhance a child’s resilience in the presence of risk factors or emergent pathological anxiety. Knowledge of such factors is important because it can inform treatment and prevention approaches. In this section, risk and protective factors for anxiety disorders are organized according to their reference to biological or genetic factors as well as characteristics of the individual, the family, or the broader social environment.

Biological and Genetic Factors Influencing Risk and Resiliency

Biological Factors

Physiological reactivity manifested as exaggerated startle response, cortisol reactivity, and a lower threshold of reactivity in the HPA axis appears to be a biological risk factor for anxiety. Supportive evidence comes primarily from studies of neuroendocrine reactivity in clinic-referred children (e.g., Granger, Weisz, & Kauneckis, 1994) and studies comparing norepinephrine levels in behaviorally inhibited (BI) and non-BI children (Weems & Stickle, 2005).

Preterm birth is also associated with increased risk of elevated anxious symptomatology and anxiety disorders (Rogers, Lenze, & Luby, 2013). For example, Rogers and colleagues (2014) conducted a longitudinal study that compared late preterm (LP) children (born at 34–36 weeks gestation) to early full-term (FT) children (born 39–41 weeks gestation). By 6–12 years of age, LP children displayed significantly more anxious symptoms than FT children. LP children also displayed alterations in right temporal lobe cortical volume, which the researchers proposed as mediating the relationship between LP birth and elevated anxiety symptoms by school age.

Genetic Factors

Anxiety is heritable, but there is still limited information regarding the genes involved (Gregory & Eley, 2011). However, the temperamental characteristics of behavioral inhibition and the combination of neuroticism and low effortful control are considered genetic influences in the development of anxiety disorders. Behavioral inhibition (BI) refers to a tendency to respond negatively to new situations or stimuli and includes behaviors such as shyness, caution, and emotional restraint (Kagan, 1997). Children with a BI temperament are four times more likely to develop an anxiety disorder, especially SocP (Beesdo et al., 2009; Blackford & Pine, 2012).

High negative affect/neuroticism (NA/N) and low effortful control (EC) place youths at increased risk for anxiety disorders (e.g., Lonigan, Phillips, Wilson, & Allan, 2011). High NA/N can lead to maladaptive anxiety through its association with processing biases in favor of threat cues. When combined with low EC, risk for anxiety is heightened because the child experiences greater anxiety and has difficulty regulating or managing it. High EC, on the other hand, can lower that risk to the extent that it diverts the child’s automatic focus on threat cues.

Family genetics are also implicated in the transmission of anxiety. Children who have one parent with an anxiety disorder are at two times greater risk of experiencing a significant anxiety disorder themselves, and at five times greater risk if both parents have anxiety disorders (Rapee, 2012). These findings are substantiated by family aggregation studies and twin studies. Heritability estimates range from 30–40%, with environment contributing to the remaining variance (Beesdo et al., 2009). Last, findings from neuroimaging studies suggest that excessive amygdala activation is an additional inherited risk factor for anxiety (Blackford & Pine, 2012).

Individual Factors Influencing Risk and Resiliency

Cognitive and behavioral characteristics also have been identified as risk factors for anxiety disorders. These characteristics include maladaptive information processing and emotional dysregulation. To date, only one characteristic of the individual has been identified as a protective factor, that is, problem-focused coping skills.

Maladaptive Information Processing

Maladaptive information processing refers to dysfunctional biases or processes relative to attention selectivity (i.e., what information is attended to), how information is interpreted or remembered, and/or how judgments are made regarding how to behave in a particular situation. Of these processes, attentional biases have received the most attention to date and two, threat biases and anxiety sensitivity, have been identified as risk factors for anxiety.

When presented with a myriad of stimuli to attend to, children at risk for anxiety manifest a proclivity to focus their attention on threatening stimuli in general (see Hadwin, Garner, & Perez-Olivas, 2006, for review) and in ambiguous situations (Drake & Ginsburg, 2012). As discussed earlier, threat biases are also highlighted in Lonigan’s model (Lonigan et al., 2011).

Anxiety sensitivity (AS) refers to a tendency to believe that symptoms of anxiety will seriously harm oneself (Reiss, 1991). AS is implicated as a specific risk factor for panic attacks and panic disorder. Longitudinal investigations have provided evidence of a causal connection between AS and PD for European-American, African-American, Hispanic, and Asian youths (Ginsburg & Drake, 2002; Weems, Hayward, Killen, & Taylor, 2002). Results from Noel and Francis’ (2011) meta-analysis (MA) included significant correlations between AS and anxiety, with the association stronger for adolescents (r = 0.36) than children (r = 0.26), and for youth with anxiety disorders compared to controls (d = 0.64). When racial/ethnic group differences were investigated, the relationship between AS and panic were significantly stronger for European American than Hispanic or Asian youth, even though the latter two groups reported more AS overall (Weems et al., 2002).

Other forms of biases and information processing differences have been investigated in clinically anxious children and in community samples with mixed results (Hadwin et al., 2006).

Emotional Dysregulation

Emotional dysregulation refers to limited awareness of one’s emotional experience and the social context in which it is occurring, and the inability to modulate emotional expression to be appropriate for the context (Jacob, Thomassin, Morelen, & Suveg, 2011). Although emotional dysregulation is not unique to anxiety disorders, anxious children engage in behaviors that could be considered ineffective attempts to regulate negative emotions. These behaviors include attempts to suppress intrusive thoughts that cause anxiety, efforts to distract oneself to avoid dealing with emotionally charged experiences, and avoidance of anxiety-provoking situations altogether (Jacob et al., 2011). All three of these behaviors could be considered coping skills, the topic of the next section.

Coping Skills

Children respond to or cope with unpleasant experiences in a variety of ways that can influence the extent to which they experience anxiety, distress, and fear (Spence, 2001). Coping strategies can be categorized as emotion-focused, avoidant, or problem-focused (Donovan & Spence, 2000). Emotion-focused strategies target the level of distress and avoidant strategies emphasize efforts to escape or avoid the problem. In contrast, problem-focused coping refers to efforts to deal directly with a problem or minimize its effect (e.g., seeking information, positive self-talk, doing something to change the situation that is creating stress). Several studies provide support for the benefits of problem-focused activities and the negative impact of emotion-focused and avoidant strategies for children and adolescents (for review, see Donovan & Spence, 2000), although others note the benefits of using coping strategies flexibly (e.g., Lewis, Byrd, & Ollendick, 2012).

Family Factors Influencing Risk and Resiliency

Parental characteristics and parent–child interactions are family factors that have a major influence on the development of childhood anxiety disorders. These factors include parental anxiety, the quality of the parent–child relationship, parenting behaviors, and parental modeling of anxious behaviors. A secure father–infant relationship has been proposed as a protective factor. These factors are discussed next.

Parental Anxiety

Parental anxiety has been associated with increased risk of anxiety disorders in offspring (Merikangas et al., 1998) and high levels of functional impairment in children with anxiety disorders (Manassis & Hood, 1998). Donovan and Spence (2000) proposed that parental anxiety might serve as an indirect risk factor and that its effects are moderated or mediated by some other mechanisms. These mechanisms could include child temperament, such as BI, discussed earlier, and parenting behaviors, discussed next.

Attachment

An insecure attachment is considered one way that family processes contribute to the development and maintenance of anxiety disorders. Insecurely attached infants typically show anxious fearfulness in difficult situations because they doubt the availability of caregivers’ assistance. A recent meta-analysis (MA) revealed an overall moderate relationship between insecure attachment and child anxiety, r = 0.30, which is stronger in adolescence than in childhood, rs = 0.36 and 0.22 respectively (Colonnesi et al., 2011). The link between insecure attachment and anxiety problems also appears stronger when a child is temperamentally predisposed to fearfulness and inhibition (Fox & Calkins, 1993).

Most of the research on attachment and anxiety has focused on the mother–child relationship. However, based on a review of the literature, Bogels and Phares (2008) concluded that a secure father–infant relationship could serve as a protective factor in preventing the development of anxiety in children. In such a relationship, fathers promote independent behaviors and encourage their children to approach new situations (instead of avoid them). As a result, children learn effective coping strategies and gain confidence in their ability to manage stressful or potentially anxiety-provoking situations.

Parenting Behavior

Parentin...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Contributors
• About the Editors
• Introduction
• Section I Foundations
• Section II Family Behavioral Health Issues
• Section III Behavioral Health Issues
• Section IV Epilogue
• Index