Anxiety Disorders in Childhood and Adolescence PDF

Anxiety Disorders in Childhood and Adolescence The Difference Between Normal Anxiety and an Anxiety Disorder: Adaptive vs. Maladaptive Anxiety Anxiety: An emotional state of psychological distress that reflects emotional, behavioral, physiological, and cognitive rea...

Anxiety Disorders in Childhood and Adolescence The Difference Between Normal Anxiety and an Anxiety Disorder: Adaptive vs. Maladaptive Anxiety Anxiety: An emotional state of psychological distress that reflects emotional, behavioral, physiological, and cognitive reactions to threatening stimuli. Two forms State anxiety: anxiety at the moment Trait anxiety: anxiety that is always with you A behavioral and physiological reaction to immediate threat, in which the person responds to imminent danger by confrontation or escape. Examples: Experiencing fear when underprepared for an exam. Manifested in increased pulse rate, shallow breathing, or even feeling dizzy. The person experiencing fear may feel a sense of terror and the urge to run away from the situation. Worry: cognitive response to threat. Adaptive anxiety: appropriate, beneficial (i.e a sense of danger) , Maladaptive anxiety: out of proportion, interference o Intensity, chronicity, degree of impairment Onset and Prevalence of Childhood Anxiety Disorders Onset of Childhood Anxiety: o DSM-5 enlists seven different anxiety disorders that can be diagnosed in children, adolescents, and adults o Four of the seven disorders occur during middle childhood: Separation anxiety disorder (SAD); selective mutism; specific phobia; social anxiety disorder. Middle childhood anxiety disorders are characterized by repeated, unwanted fears of objects and situations. SAD, selective autism, specific phobia, and social anxiety disorder are together considered fear disorders. o The fifth and sixth disorders are rare in children before puberty: Panic disorder and agoraphobia. Both are characterized by feelings of intense apprehension, dread or panic and can often occur together. o The seventh type of anxiety disorder is generalized anxiety disorder (GAD) that is underlined by persistent worry as against fear or panic. It usually sets in after later late childhood or adolescence since the ability to contemplate on future events, marked by worry, is more prevalent in older children. Prevalence and Course: o Approximately 20% children and adolescents are known to develop some form of anxiety disorder before adulthood. o Amongst adults, the prevalence is roughly about 5%. o Prevalence is higher for adolescents than younger children and in girls than boys, the latter ratio being as high as 1:2 or even 1:3 during adolescence. o Childhood anxiety disorders are a predictor for: Depressive disorder, substance use and suicide behaviors. o Anxiety and the development of depression have been found to be at a gap of 5 years, on average. Separation Anxiety Disorder: A DSM-5 disorder characterized by a developmentally inappropriate and excessive fear of separation from caregivers; lasts at least 4 weeks in children and causes distress or impairment in functioning.  o Fear of harm to self or others o Onset usually between 7 and 9 years of age Emergence and decline of fear of separation: o SAD emerges in infants at 6 months of age, and peaks between 13 to 18 months. o With a more firm trust established in caregivers, older infants and toddlers tend to display separation anxiety. o Separation anxiety should typically decline around the age of 3 to 5 years. Varied symptoms across ages: o Young children, of around 7 years of age, may refuse to go to school or display a tendency to cling to their parents. o Many young children with SAD experience nightmares about their parents being harmed and insist on having them close while sleeping. o To ensure proximity, children with SAD might choose to sleep outside their parents’ room, if denied a request to sleep together. o A 12-year old with SAD, on the other hand, may experience diffuse fears of separation. o Older children might admit to a vague sense of feeling endangered if they are separated from their parents. o Older children may engage with separation in better ways than younger ones, but still experience extreme anxiety and sadness on separation. o Many older children might fall ill, withdraw from social situations, have a hard time concentrating, and experience depression. o SAD may compel young children to distance themselves from peers in order to be with their families, thus significantly hampering their social and academic functioning. o Onset of SAD is usually between 7 and 9 years of age. Genetic factors have small contribution compared to other ADs. Insecure attachment: inconsistent support/presence Parents’ anxiety and insecurities o Controlling, overly involved, overprotective style may model anxiety Selective Mutism Consistent failure to speak in social situations. Dx only when the child’s inability to speak cannot be attributed to a lack of knowledge or another disorder (i.e. ASD) Rare, can be long-term, precursor for Social Anxiety d/o. Selective mutism as a rare condition: o Affects less than 1% children in the general population. o Some studies suggest twice the likelihood of occurrence in girls than boys. o Likely onset between the ages of 2.7 to 4.2 years. o Usually goes undiagnosed before going to school when children with selective mutism refuse to speak to classmates and teachers. Selective mutism as a long-term condition o Can last for an average of 8 years, without treatment. o An alarming 94% of children who do not receive treatment for selective mutism, go on to develop social anxiety disorder, resulting in anxiety and avoidance of social situations. o Because of the failure to speak, children with selective mutism may also face academic difficulties and peer rejection. Interplay of genetics, temperament, early social learning o An allele for a certain gene, CNTNAP2, predisposes children o Behavioral inhibition Mowrer’s two-factor theory of anxiety o Emerges through classical conditioning, negative reinforcement maintains o Associate not speaking with not getting into trouble Specific Phobia Marked anxiety about specific object. o Animals, natural environment, blood, specific situations (i.e. planes, elevators, the dark), other stimuli (i.e. costumed characters) Distress, dysfunction (i.e. avoidance), sxs for at least 6 mos. Symptoms: racing heartbeat, shallow breathing, sweaty palms, dizziness, other bodily symptoms (vasovagal response) o Younger children may cry, freeze, cling, tantrum o Extreme pain manifested in racing heartbeat, shallow breathing, sweaty palms, dizziness, and other bodily symptoms. o Younger children with specific phobia might cry, throw tantrums, freeze or cling to their parents excessively. o Children with specific phobia may start avoiding situations that might cause fear. o Fears so displayed are usually out of proportion in correspondence to the actual danger brought by the external stimuli. Fear is out of proportion compared to actual danger Classical conditioning, observational learning, informational transmission, maintained by negative reinforcement (Mowrer’s) Diagnosis and prevalence of specific phobia: Children merit diagnosis for specific phobia if they meet two criteria: o The anticipatory fear or anxiety disrupts their daily functioning. o Symptoms cause significant distress in children. Prevalence: o 2% to 9% of children and adolescents suffer from specific phobia, the most common being from animals. o About 3% to 7% fear natural stimuli, while 3% to 4.5% fear blood, injection, and injuries. o 3% to 4% younger children fear the dark. o Girls are more likely to experience specific phobia than boys. o 91% girls report fear of animals, 87% experience fear of specific situations, while 70% experience fear of natural disasters. o Children experience changes in cognition while faced with a feared stimuli, like making negative self- statements that reduces their ability to cope. o Physiologically, children experience decreased autonomic functioning in response to feared stimuli. o Behaviorally, children are experience the urge to flee a situation, and failure to do so may lead them to become clingy, panicky, or irritable. o Phobias can last for up to 2 years, causing distress and impairment, if not treated in time.  Social Anxiety Disorder Marked anxiety about social situations, sxs for at least 6 mos. Symptoms: immediate anxiety or panic, fear of judgment or negative evaluation (speaking, performing), social avoidance, socioemotional impairment, must cause distress and dysfunction o When faced with a feared situation, children with social anxiety disorder display immediate anxiety or panic symptoms. o For such children, feared situations include any social setting where they might be judged, criticized, or negatively evaluated. o Examples of social anxiety disorder include fear of public speaking, a party or social gathering, a performance in front of other people. o The disorder is accompanied by feeling of embarrassment, or fear of being called crazy or stupid by others. o Some children with social anxiety disorder may only fear public performances and not other social gatherings. o Youths with social anxiety fear two most common situations that include formal presentations and unstructured social interactions. o Causes distress in children. o Social and emotional functioning are severely impaired. o Leads to social avoidance which is negatively reinforced by reduction in social anxiety, which can lead to reduced interactions with peers Diagnosis usually after age 10. Usually emerges in late childhood or adolescence Behavioral inhibition, genetics, modeling Common to have parents with Social Anxiety d/o, parents with hostile, critical, controlling or overprotective style Prevalence and course of the disorder: o About 60% of children with this disorder report problems at school o 53% of such children lack friends, while 27% experience difficulty in sports and other leisure activities. o Social anxiety disorder can also lead to depression, social isolation, and loneliness. o Substance use is also one of the fallouts of social anxiety disorder. - Panic Disorder Recurrent, unexpected panic attacks o Acute and intense episode of psychological distress and autonomic arousal; can occur by itself or in the context of an anxiety d/o o Panic attack: An abrupt surge of intense fear or discomfort that reaches a peak within 10 minutes and is characterized by heightened negative affect and physiological arousal; can occur by itself or in the context of an anxiety disorder Symptoms of panic attack: cognitive, emotional, somatic; most common heart palpitations and dizziness Young adults and adolescents report two most common symptoms: o When faced with a feared situation, children with social anxiety disorder display immediate anxiety or panic symptoms.  o Palpitations or a pounding heart by 78% to 97%. o Dizziness by 73% to 96%. Least common symptoms include: o Numbness or tingling sensations by 26% to 29%. o Choking by 24%. Prevalence and course of panic disorder: o When faced with a feared situation, children with social anxiety disorder display immediate anxiety or panic symptoms. o Panic disorder is relatively common in adolescents with at least 18% teens having experience a full-blown panic attack. o 60% adolescents are also known to experience sub-threshold symptoms of panic. o Almost equal prevalence in boys and girls, but may be more severe in girls. o Panic disorder, as against panic attacks, is pretty uncommon in adolescents, and almost rare in children. o Although panic disorder usually occurs between the ages of 15 to 19, there are also isolated incidents of it occurring before puberty. o Adults with panic disorder also increase the risk of their children developing SAD. o On the other hand, children with SAD are 3.5 times more likely to develop panic disorder in late childhood or adolescence. o Furthermore, children with SAD, and adults with panic disorder may exhibit subtly abnormal respiration that make them more susceptible to panic symptoms. o Metacognition: : The ability to think about one’s own thoughts and feelings. Younger children who have experience a panic attack are also known to worry less about another one or its implications. This might be due to the cognitive immaturity that prevents them from worrying about recurrent panic. Diagnosis of panic disorder: 1 mo. of worry about future attacks (metacognition), must cause distress and dysfunction Anxiety sensitivity, expectancy theory o Perceiving any anxiety as highly negative, personalizing negative events, catastrophic thinking Agoraphobia Marked anxiety about places or situations from which escape is not possible without considerable effort or embarrassment. Derived from the Greek word agora, which was the central meeting place in ancient Greek city-states. Symptoms and effects of agoraphobia: avoidance, panic-like symptoms or attacks, social and educational impairments People with agoraphobia tend to avoid public places like shopping malls, movie theatre, stadiums, or any other place where exit is difficult, like airplane or subways. Signs and symptoms include panic attacks, or panic-like symptoms. Agoraphobia leads to avoidance of feared situations. Agoraphobia restricts social and educational functioning in adolescents by limiting their ability to attend school, participate in after-school activities or spend time with friends.  Adolescents may also be forced into agoraphobia: o An adolescent who is afraid to step out of home, will eventually have to go to school. o In such situations, adolescents experience extreme emotional distress and discomfort. o In some cases, a parent or a close friend can provide them with reassurance and safety. Classical conditioning and negative reinforcement (i.e. school avoidance) Genetic and environmental factors o 61% heritability rate; associated with low warmth, high demand (parents hold high expectations but offer little support), overprotective families who hold beliefs that the world is full of threats Absence of panic disorder: panic-like symptoms lead to avoidance in order to prevent attacks Prevalence of agoraphobia: o Agoraphobia is rarely present in adolescents. o About 1.7% adults experience agoraphobia, while the percentage is just 0.5% in adolescents. o Typically sets in between the ages of 18 to 29 years. o Disorder sets in gradually as individuals come to fear an increasing number of places and situations. o Agoraphobia can last throughout adulthood, if not treated. Generalized Anxiety Disorder Worry, not fear or panic, is primary symptom o Adults with GAD worry too much about aspects of daily life, like completing tasks at work, managing finances or performing household chores. o Children and adolescents with GAD worry about things like exams, school assignments, and co-curricular activities. o GAD also causes worry about relationships with friends, family well-being, and daily hassles. Apprehensive expectation – excessive worry about the future and daily life which causes distress and interferes with function Risk factors similar to anxiety disorder (difficult temperament, behavioral inhibition, poor parent-child interactions) Cognitive distortions: catastrophizing, overgeneralizing, personalizing Worries similar, but greater in number, intensity, and impairment level Worry as a cognitive activity: o When faced with a feared situation, children with social anxiety disorder display immediate anxiety or panic symptoms. o Marked by repeated and increasingly elaborated thoughts about negative events in the future and their possible consequences. o First signs of worry usually surface between the ages of 4 or 5, followed by the development of the ability to think and dwell upon negative events in the future after the age of 8. o GAD usually develops with this development of cognitive capacity to dwell on future events between the ages of 8 and 10. o With increasing capacity, the frequency and severity of GAD also goes up.  o Children with or without GAD usually dwell on the same topics of school, sports, relationships, and future goals. o Number intensity, and duration of worries differentiate between children with and without GAD: Individuals with GAD report a greater number of worries, GAD-related worries are more intense and distressing, and can cause impairments through daytime restlessness, sleep disorders, fatigue, muscle tension, irritability, and difficulty in concentrating. Individuals with GAD spend a greater proportion of their time worrying than those without GAD. Interference with children’s daily lives: o GAD also interferes with daily functioning of children: The distress caused by worries takes up time and energy. Worry disrupts children’s ability to pay attention to parents or completing their homework. Worry causes mood problems, frustration, and irritability. Worry is also a contributor to physical problems such as headache, insomnia or fatigues. Worry inhibits the development of more adaptive coping strategies. o DSM-5 requires the display of at least one symptom of worry in children, and at least 3 in adults. o Parents often label children with GAD as little adults who are often perfectionists, punctual, and eager to please. Association with other problems: o Approximately 50% children with GAD also have depression. o Children with GAD are at a higher risk to develop depression in later life. o According to a study by Moffitt and colleagues, in 68% of individual participants with GAD and depression, anxiety problems either preceded or occurred simultaneously with their depressive symptoms. o On an average, adolescents tend to develop depression 5 years after the emergence of anxiety. o According to factor analysis, GAD and depressive symptoms tend to naturally co-occur in the general population. o Factor analysis or the statistical method to identify underlying constructs or factors that relate observable traits or symptoms, is performed by identifying clusters of symptoms that tend to occur simultaneously. o Multiple factor analyses attribute children’s internalizing symptoms to two factors: Fear factor that explains the relationship between anxiety, fear, and panic. Anxious-misery factor that explains the relationship between GAD, major depressive disorder, and dysthymic disorder. o Children with GAD have higher chances of developing depression than fear or panic. Obsessive-Compulsive And Related Disorders Obsessive-Compulsive Disorder: A DSM-5 disorder characterized by obsessions and/or compulsions that are time consuming and cause significant distress or impairment Obsessions: Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted. o Characterized by:  Thoughts about contamination like touching dirty objects Recurrent doubts like wondering if someone left the door open. Need for order or symmetry like arranging towels in a certain way. Aggressive or horrific impulses like thoughts about swearing in church. Sexual imagery. o Most people with OCD tend to ignore or suppress their obsessions, leading to anxiety, tension, or distress. Compulsions: Repetitive behaviors or mental acts that an individual feel driven to perform in response to an obsession or according to specific, inflexible rules. o Common compulsions can include washing, cleaning, counting, checking, repeating, arranging, and ordering. o Usually performed in a rigid manner following some idiosyncratic rules. o Examples: An adolescent with recurrent obsessions with sexual imagery may feel compelled to pray in order to reduce anxiety or guilt. A mistake in her prayers may lead her to constant repetition unless perfected. About 1-2% of children meet criteria, 41% of these continue to show symptoms after 5 years, 90% remain untreated Approximately equal contributions of genetics and non-shared environment Learned associations, negative reinforcement, neural pathway Symptoms of OCD: o Common compulsions can include washing, cleaning, counting, checking, repeating, arranging, and ordering. o Many adults and adolescents with OCD might deem the unwanted thoughts or urges to be just products of their own minds and unlikely to come true. o In contrast, younger children with OCD are almost convinced of their obsessions coming true o DSM-5 requires specification of an individual’s insights into her obsessive-compulsive symptoms. o People with good insight may be more motivated and inclined to participate in treatment. Disorders Related to Obsessive-Compulsive Disorder Tic Disorders: Sudden, nonrhythmic, stereotyped behaviors o Vocal or motoric o Copropraxia, coprolalia, echopraxia, echolalia o Simple tics: Last for a few milliseconds and are characterized by one type of motor behaviour like an eye blink or a shrug, or vocalization as in a click or a grunt. o Complex tics: Last several seconds and usually combine several simple tics like simultaneous head turning and shrugging. o People with tics can:  Make sexual or obscene gestures called copropraxia. Utter inappropriate slurs called coprolalia. Imitate others’ movements called echopraxia. Repeat sounds or words called echolalia. o Characteristics of tic disorders: Tics are similar to OCD in the sense that both involve a series of events involving a stimulus being followed by a habitual response. In OCD, stimulus is an obsession and the response is a compulsion. For tics, the stimulus is a sudden and unwanted rage, while the response is a motor or vocal behaviour. Both tics and OCD can be suppressed for a short duration, but can cause much greater discomfort if held back for long o Differences between tics and OCD: People suffering from OCD almost always respond with compulsions to certain obsessive thoughts or mental images. Not all people with tics, on the other hand experience obsessive thoughts that lead to their motor or vocal behaviours. Half the people with tics report specific obsessions that they experience before an episode which mostly include thoughts about symmetry or order. Between 50% to 80% of people with tics also report premonitory urges that have a physical quality like an itch or muscle tension, prior to experiencing a tic. Tics range in severity from mild to severe, translating into unwanted urges similar to scratching the nose or sneezing. Tics are mostly involuntary. o Types of tic disorders: According to DSM-5, tics can be arranged in a hierarchy from least to most severe: Provisional tic disorder, characterized by a single or multiple motor or vocal tics or a combination of both, lasting for about a year. Persistent motor or vocal tic disorder is characterized by multiple motor or vocal tics that lasts for more than a year. Tourette’s disorder: A DSM-5 disorder characterized by the presence of multiple motor and vocal tics lasting for more than 1 year. Less than 10% of individuals with Tourette’s disorder is marked by coprolalia. o Prevalence, onset and comorbidity: Lifetime prevalence ranges from 0.4% to 1.8%. Almost 2% to 4% of children and adolescents suffer from chronic tic disorders. 5% to 18% youths may experience transient tics during stressful times. Boys are 2 to 10 times more likely to contract tics than girls. Median age of onset is 5.5 years. Both OCD and tics usually decline over time and maybe aggravated at times of psychological stress.  Tic symptoms usually peak during early and middle adolescence, and start decline toward early adulthood OCD and tic disorders are highly comorbid, with almost 25% to 50% with chronic tics or Tourette’s likely to develop OCD at some point Approximately, 30% youths with OCD also suffer from chronic tics or Tourette’s disorder. Tics are rare in the general population and its comorbidity with OCD indicates a common underlying cause. Both tics and OCD can be hereditary. The concordance of tics among monozygotic (MZ) twins lies between 77% to 94%, while dizygotic (DZ) twins, it is only 23%. Children with tic disorders are likely to have a 15% to 53% chance of having biological relative with a tic disorder and 10 to 20 times more likely than normal children to have a relative with OCD. Trichotillomania: repeated pulling out of hair (focused or automatic) Excoriation Disorder: recurrent skin picking Evidence-Based Treatment Behavior Therapies Exposure therapy: A form of behavior therapy used to treat anxiety and related disorders; involves repeatedly confronting feared stimuli for discrete periods of time until anxiety or negative affect dissipates o Vocal or motoric o Exposure can be graded or gradual, and rapid. o Can be a vivo exposure where children confront real objects, people or situations or it could be imaginal exposure. o Exposure can be spaced, occurring over a number of weeks or could be massed, occurring over a number of hours or days. o Systematic desensitization o Flooding o Modeling Contingency management: positive reinforcement for confronting a feared stimulus without being allowed to avoid or escape the stimulus Efficacious with specific phobias and selective mutism Mary Cover Jones experiment: o A student of John Watson, Mary used behavioral techniques to reduce fear in a preschooler named Peter who was scared of rabbits. o First, Peter was exposed to a rabbit for progressively longer periods of time. o Initially, the rabbit remained in one side of the room in a cage, and in subsequent sessions was brought closer to Peter, who was encouraged to touch it. o In the second step, Peter was positively reinforced for touching the rabbit by being rewarded with a candy. o In the third step, Peter was encouraged to play with other children his age, who were not afraid of rabbits, in the presence of the rabbit. o Peter observed the other children pet and play with the rabbit without fear, leading to a reduction in his fear over the course of several weeks.  Cognitive–Behavioral Therapy for Separation Anxiety Disorder, Social Anxiety Disorder, and Generalized Anxiety Disorder o CBT: integrated therapy: The integration of cognitive and behavioral interventions to produce behavior change; relies on the premise that changes in thoughts or overt actions can affect emotions. Treatment phases: o Education: Children are taught the relationship between thoughts, feelings, and actions. Children are subsequently taught new coping methods to deal with anxiety and worry. The entire therapy is designed on the elements of FEAR, combining feelings, expectations, attitudes, and results. A child can use the FEAR plan to confront an anxiety-provoking situation. In the first step, children learn to identify feelings and physical sensations, that contribute to their anxiety In the second step, children learn to recognize and modify negative thoughts and cognitive distortions that compel them to expect bad things to happen. Through the use of workbooks, games, and role-plays, the therapist demonstrates how a change in thoughts can lead to a change in feelings and actions. Therapists help children with anxiety disorders reduce the frequency of negative self-statements. According to Kendall (1992), the goal of therapy is to teach children “the power of nonnegative thinking.” The therapy’s success depends on the reduction of negative thoughts. o Practice This phase includes the application of FEAR technique in the community. This involves graded exposure that depends on the child’s disorder. Children with social anxiety disorder might simple be asked to approach a group of children playing. Children with SAD might be encouraged to stay away from their parents for 15 minutes while shopping Consequently, children may report feeling intense anxiety, initially. However, habitual exposure to anxiety-causing situations, helps anxiety levels to drop and encourages children to believe that such exposure does not lead to catastrophe. Efficacy: improved self-reports, parent-reports, and behavioral observations compared to controls o Relaxation, cognitive restructuring, exposures o Research in CBT has typically involved children between the ages of 7 to 13 years, with social anxiety disorder, SAD, and GAD. o CBT has led to improved self-reports, parent-reports, and behavioral observations of children with anxiety symptoms, compared to controls. o Clinically significant reductions in anxiety are observed: Most CBT participants no longer meet diagnostic criteria for anxiety disorders after treatment. Benefits of treatment are seen to last for up to 7 years. o Research has indicated at two important components of CBT:  Exposing children to feared stimuli. Challenging children’s negative thoughts about feared events. o An assessment by Peris and colleagues (2015) revealed significant anxiety reduction in children exposed to feared stimuli, who were taught to challenge distorted thinking, as against children taught to use relaxation techniques alone. Development of therapy: o Relaxation, cognitive restructuring, exposures o CBT treatment packages have been modified to facilitate participation by computer. o A computer-administered version of Coping Cat has been developed for children with social anxiety disorder, SAD, and GAD o Other such programs include Camp Cope-A-Lot, and BRAVE for Children. o Programs like BRAVE for Adolescents and Cool Teens cater to the needs of adolescents. o These programs can be used to supplement traditional CBT programs or used as its substitute in rural communities. Cognitive–Behavioral Therapy for Panic Disorder Relaxation training: A cognitive–behavioral intervention designed to reduce physiological arousal and avoid panic; usually involves muscle relaxation, controlled breathing, and pleasant imagery or self-statements. Interoceptive exposure – biological challenge. A behavioral intervention unique to the treatment of panic disorder; the person intentionally produces physiological symptoms of panic and then uses relaxation techniques to cope with these symptoms. o Mimicking panic symptoms can have three benefits: Adolescents understand that panic symptoms can be produced intentionally, and thus are not always beyond control. Adolescents learn that panic will not cause them to die or pass out and although distressing, it can decrease over time. Adolescents realize the importance of relaxation techniques to cope with panic symptoms. Cognitive restructuring – challenging biases and distortions.Cognitive interventions that involve challenging biases and distortions that lead to negative emotions by looking for objective evidence to support them. o A therapist might play the detective game with an adolescent to encourage them to critically evaluate the likelihood of a catastrophe during a panic attack. Graded in vivo exposure – systematic desensitization Highly efficacious; however, limited pediatric data o Most randomized controlled studies are of adults Cognitive–Behavioral Therapy for Obsessive-Compulsive and Related Disorders Information gathering. o The first component of CBT treatment package for youths with OCD. o The clinician usually interacts with the parents and child to obtain information about the family’s psychosocial history, the child’s symptoms, and the onset and course of the disorder. o This helps the therapist determine the exact nature of obsessions and compulsions being experienced by the child. o Treating ritualistic actions like hand washing would require a different approach than treating mental rituals like counting or praying. Exposure and response prevention: A behavioral intervention used to treat OCD; involves exposing oneself to a series of stimuli that elicit obsessions and avoiding their corresponding compulsive behaviors o EX/RP uses the principle of extinction with the initial exposure causing a rapid surge of distress, and gradual decrease of distress over time o Cognitive therapy, along with EX/RP stands to benefit older children and adolescents.  o Cognitive therapies may not directly help reduce OCD behaviors, but help children in engaging in the EX/RP exercises. o Therapists may also use cognitive restructuring to help children view feared situations more realistically than in an excessively negative light. o Children are also taught to replace self-defeating and negativistic self-statements with more realistic ones. Generalization – parents taught to coach children through EX/RP o The final component of CBT is generalization training and relapse prevention. o In this treatment, parents are taught to coach their children through the EX/RP tasks. o Parents and children are encouraged to confront feared stimuli outside the therapy as well. o The final sessions involve discussions between parent, child, and therapists on what to do in case symptoms return. o Most therapists encourage children and parents to look at relapses as learning experiences rather than as failure. o In case of a relapse, EX/RP techniques can be used or the therapist can be approached for support. Efficacy: Youths with OCD report 50% to 67% symptom reduction from initial participation in CBT o Can be combined with medication for those who do not respond to CBT alone o Symptom reduction have been seen to persist after treatment. o EX/RP is claimed to be the most critical component of CBT. o Relaxation training and cognitive interventions, although useful, are not critical for success. In addition to CBT, Tic Disorders, Trichotillomania, and Excoriation may be treated with self-monitoring and habit reversal training Medication for Childhood Anxiety Disorders Selective serotonin reuptake inhibitors (SSRIs): o Medications like fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and paroxetine (Paxil) are found to be more effective than placebo o Across studies, approximately 45% to 65% of youths prescribed these medications show at least moderate improvement. CBT and medication: o The Child/Adolescent Anxiety Multimodal Study (CAMS) compared various treatments for 488 youths with SAD, social phobia, or GAD (Walkup et al., 2008). o Youths in the study were randomly assigned to one of four conditions: Sertraline (Zoloft) alone. CBT alone. Sertraline and CBT. Placebo. o The first three were found to be more effective than placebo, while those who received both sertraline and CBT were much more likely to improve than those with either of the two.  SSRI efficacy: o Effective in young children with selective mutism, with about 84% showing improvements after taking an SSRI. o Most studies on the usefulness of SSRI, however, do not include control groups, necessitating the need to interpret results cautiously. Medication for Obsessive-Compulsive Disorder and Related Disorders Pediatric OCD Treatment Study (POTS; 2004): 112 youths with OCD, ages 7 to 12 o 112 youths with OCD, aged between 7 to 12 were assigned to one of four groups: Sertraline (Zoloft) alone. CBT alone Sertraline and CBT. Placebo. o After 12 weeks of receiving treatment, children in the third group who received both sertraline and CBT showed greater symptom reduction than those who received either of the two. o Youths who received either sertraline or CBT demonstrated almost equal reductions in symptoms, but higher reduction than those who received placebo. o 53.6% of children in the combined group showed no significant OCD symptoms after the treatment, while in CBT-only or medication-only groups, this percentage was 38.3% and 21.4% respectively. o In the placebo-only group, a mere 3.6% children showed no significant OCD symptoms after the treatment. CBT and medication: o The POTS study proved that CBT, along with medication is more effective than only medication. o However, there are challenges to this: CBT takes multiple sessions to implement. Insufficient number of trained clinicians in CBT for children. o To understand if providing children and parents with CBT information and instructions on use of EX/RP might be as effective as actual CBT, there was another study by a second POTS team: o 124 children and adolescents with OCD were randomly assigned to one of three groups: Sertraline alone Sertraline and CBT both. Sertraline along with information on OCD and instructions on EX/RP. Results indicated that 68% of those who received both medication and CBT were significantly more likely to improve than those with medication alone (30%) or medication with instructions (34%). In addition, a trained CBT therapist also seemed to be potent to effective treatment. Tics and related disorders: o Pharmacotherapy aims to reduce, but not eliminate tics. o Medication is used to reduce tics to a level that allows children to function at home, school, and with peers, without a lot side effects. o Antipsychotic medication is often recommended to block dopaminergic activity in the brain. o Older medications like haloperidol (Haldol), and pimozide (Orap), as well as newer medications like risperidone (Risperdal), and ziprasidone (Geodon) can reduce tics by 22% to 56%, compared to a 16% reduction with placebo. o However, 40% individuals are known to discontinue these medications on account of side effects like sedation, weight gain, and metabolic problems. o The alpha-2 adrenergic agonists offer a second class of medications for treatment of tics. o These medications are known to affect the median raphe area in the brain, reducing dopamine activity. o The medications also reduce tics without the side effects of antipsychotic drugs.