case study of a child with anxiety disorder

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Hannah, an anxious child

Hannah (not a real person) was a 10-year-old girl from a close, supportive family who was described as 'anxious from birth'. She had been a shy, reserved young girl at pre-school, but she integrated well in grade 1 and began making friends and succeeding academically. She complained several times of severe abdominal pain that was worst in the morning and never present at night. She had missed about 20 days of school during the previous year because of the pain. She also avoided school excursions, fearing the bus would crash. She had difficulty falling asleep and frequently asked her parents for their reassurance.

Hannah was worried that she and members of her family might die. She was unable to sleep at all before a test. She could not tolerate having her parents on a different floor of the house from herself, and she insisted on securing the house to an unnecessary extent in the evenings, fearing intruders. Her insecurity, need for constant reassurance, and school absenteeism were frustrating and upsetting for her parents.

Hannah had no personal history of traumatic events. She exhibits symptoms typical of childhood anxiety disorder, which is thought to occur in about 10% of children, equally in boys and girls before puberty. This type of disorder is diagnosed when anxiety is sufficient to interfere with daily functioning, for example Hannah's school attendance and sleep. These effects can increase and interfere to a progressively greater extent with age-appropriate functioning at home, at school and with peers, and also places sufferers at risk of developing mood disorders or substance abuse disorders in the future.

Many children experience fears; fears that are developmentally normal. Children with anxiety disorders, however, experience persistent fears or other symptoms of anxiety for months. Children can experience all the anxiety disorders experienced by adults. However, they can also experience separation anxiety disorder and selective mutism (failure to speak in certain social situations, thought to be related to social anxiety), which are unique to children. The duration of Hannah's difficulties and the symptoms, including inability to sleep, attend school regularly, go on school excursions, or face tests without extreme distress are all developmentally inappropriate, suggesting an anxiety disorder.

There is a range of common symptoms seen in anxious children. Symptoms involving thoughts include worrying, requests for reassurance, 'what if.' questions, and upsetting obsessive thoughts. Common symptoms involving behaviours include difficulty in separation, avoiding feared situations, tantrums when faced with fear, 'freezing' or mutism in feared situations, and repetitive rituals, or compulsions. Common symptoms involving feelings include panic attacks, hyperventilation, stomachaches, headaches and insomnia.

To screen quickly for one or more anxiety disorders in children, four questions are often useful:

• Does the child worry or ask for parental reassurance almost every day?
• Does the child consistently avoid certain age-appropriate situations or activities, or avoid doing them without a parent?
• Does the child frequently have stomachaches, headaches, or episodes of hyperventilation?
• Does the child have daily repetitive rituals?

These questions address the main thoughts, behaviours and feelings related to anxiety seen in children.

Megan Rodgers wishes to acknowledge an article entitled 'Childhood Anxiety Disorders' written by Dr Manassis, a Staff Psychiatrist at the Hospital for Sick Children and the Center for Addiction and Mental Health in Toronto, Ontario, on which this article is based.

Written by Megan Rodgers ADAVIC Volunteer June 2004

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• Volume 32, Issue 6
• Very early family-based intervention for anxiety: two case studies with toddlers
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• http://orcid.org/0000-0001-5603-6959 Dina R Hirshfeld-Becker 1 , 2 ,
• Aude Henin 1 , 2 ,
• Stephanie J Rapoport 1 ,
• Timothy E Wilens 2 , 3 and
• Alice S Carter 4
• 1 Child CBT Program, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
• 3 Division of Child and Adolescent Psychiatry, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 4 Department of Psychology , University of Massachusetts Boston , Boston , Massachusetts , USA
• Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}partners.org

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

• childhood anxiety disorders
• preschoolers
• cognitive behavioural therapy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/gpsych-2019-100156

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Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

• View inline

Application of treatment protocol with both participants

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

Quantitative changes in diagnoses, coping ability, symptoms and family function in both participants

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Acknowledgments

The authors acknowledge Jordan Holmen for assistance with data checking.

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Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

Patient consent for publication Parental/guardian consent obtained.

Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Generalized anxiety disorder in kids.

When near-constant worry affects your child’s well-being

Writer: Shelley Flannery

Clinical Experts: Emily Gerber, PhD , Jerry Bubrick, PhD

What You'll Learn

• How is generalized anxiety disorder different from other forms of anxiety?
• What do kids with generalized anxiety disorder worry about?
• How can we help kids with generalized anxiety disorder?

Most kinds of anxiety focus on a particular worry — fear of heights, separating from parents, speaking in public, things like germs or spiders.  But some kids are anxious about many things. They have what’s called generalized anxiety disorder or GAD.

Kids with GAD worry about everything, and it often takes the form of “what ifs”:

“What if we run out of gas?

“What if mom loses her job?

“What if a hurricane blows away our house?

“What if I get a bad grade?”

Kids with GAD tend to imagine the worst happening, and  their anxiety may not be triggered by anything in particular. They may be irritable and have trouble sleeping.

Kids with GAD also tend to be perfectionists. They may put enormous pressure on themselves to perform well — more than their teachers or parents — and may avoid doing things because they’re worried about not doing them well enough. They may have anxious stomachaches and headaches and spend a lot of time in the school nurse’s office.

It’s important to get help for kids with GAD because all that worry can lead to depression, and it also leads, for teenagers, to substance use —drinking alcohol or smoking pot to ease their anxiety.

Treatment for GAD includes cognitive behavior therapy (CBT), in which kids learn to recognize irrational thinking and replacing it with more logical, healthy ways of thinking. An alternative is acceptance and commitment therapy (ACT), which teaches kids to acknowledge and accept the anxious thoughts they’re having and commit to moving forward despite them. Parents also learn how to avoid enabling their child’s anxiety and instead support their overcoming it.

Severe GAD may be treated with a combination of therapy and medication, usually an antidepressant called an SSRI.

For a lot of kids with anxiety, excessive worry is triggered by a specific situation, such as being away from their parents, public speaking, heights or a scary animal. But kids who worry excessively about numerous things may have generalized anxiety disorder.

Generalized anxiety disorder (GAD) is characterized as constant worry about lots of different things that aren’t really threats and/or overreacting to minor threats. It’s the most common type of anxiety disorder among children and teens.

Unlike with a phobia, which has a specific trigger — spiders, needles, dogs, airplanes, clowns, etc. — children with GAD worry about a variety of everyday situations.

“Kids with generalized anxiety disorder worry about all the same things that other kids worry about,” says Emily Gerber, PhD , the senior director of the Anxiety Disorders Center at the Child Mind Institute’s San Francisco Bay Area clinic, “but they worry more often and more intensely.”

There doesn’t even necessarily have to be anything that triggers it, adds Dr. Gerber. “It’s sort of always  there.”

Si gns of GAD

“Kids with GAD are chronic worriers,” says Jerry Bubrick, PhD, a senior clinical psychologist at the Child Mind Institute. “There’s no area that they don’t worry about, but the typical areas of worry are usually around health of themselves or their family, money, and safety and stability.”

Kids with GAD worry about the “what if’s,” adds Dr. Bubrick.

“What if we run out of gas?”

“What if mom loses her job?”

“What if a hurricane blows away our house?”

They tend to imagine the worst happening, and seek reassurance from parents that it won’t.

Dr. Bubrick has seen kids, for example, who are super worried if a big storm is coming in. Then, if nothing bad happens, they’re worried about another storm coming. What if we’re not as prepared next time? They’re glued to the weather reports with excessive worry.

Dr. Gerber describes a child who developed GAD during the pandemic. “His aunt was in the ICU for a while during COVID, and so he started to become overly concerned about everybody around him,” she says. “He was constantly asking, ‘Are they going to be okay?’ and didn’t want anyone to go out because he was so worried they would get sick.”

Other signs of GAD in children and teens include:

• Restlessness or feeling on edge
• Apprehensiveness
• Indecisiveness
• Being easily fatigued, especially at the end of the school day
• Irritability
• Trouble sleeping
• Difficulty concentrating or feeling their mind go “blank”
• Catastrophizing or always expecting the worst

Kids with GAD are perfectionists

Most kids feel anxious about their performance in school from time to time and may worry about an upcoming test or presentation. A child with GAD, however, is likely to take that worry to an extreme, and study obsessively even though they already know the material.

“There’s one 9-year-old in particular I’m thinking of whose parents are very ambitious and so he only wants to get A-pluses at school,” Dr. Gerber says. “He has this terrible fear that if he submits an assignment and it’s anything less than perfect, his life is going to be ruined. As a result, he’s developed some avoidant behaviors. He either is distressed or he’s so avoidant that he completely forgets about the assignment.”

Dr. Bubrick adds that some kids with GAD are such perfectionists that they don’t want to do anything unless they can be the best at it. “They will think, ‘If I can’t be the best at something, then why try? If I can’t be a rock star, then why take guitar lessons?’ “

They may have anxious stomachaches and headaches and spend a lot of time in the school nurse’s office.

Who’s at risk?

GAD can develop in children as early as 5 but is most frequently diagnosed in adolescents. It tends to affect girls more than boys, but all genders can develop the disorder. Kids with sensitive temperaments are more likely than others to develop generalized anxiety.

The largest predictor of GAD in children and teens is family history. Kids who have one parent with any kind of anxiety disorder are more likely to have generalized anxiety than other kids; those with two parents with anxiety are significantly more at risk. Experts believe the risk stems from a combination of biology and learned behaviors — seeing how a parent deals with stress and worry and emulating that behavior.

And if there’s one thing kids today have an abundance of, it’s stress. Rates of anxiety had already been on the rise when COVID-19 hit the U.S. in March 2020. The pandemic accelerated the development of the disorder in many young people. Between 2016 and 2020, anxiety rates among kids had increased from 7.1% to 9.2%, according to a study published in JAMA Pediatrics whereas a review published just a year later in the Journal of Psychiatric Research reported rates of anxiety among kids were between 19% and 24%.

“The pandemic was a major anxiety trigger for a lot of Americans, especially kids, who rely on school for most of their socialization,” Dr. Gerber says. “And unfortunately, we have yet to see rates of GAD slow down. We’re still seeing kids with anxiety levels parents say they’ve not seen before.”

When GAD goes untreated

Without treatment, GAD typically worsens over time. If you suspect your child might have generalized anxiety disorder, it’s a good idea to get them evaluated. The sooner GAD is diagnosed and treated, the fewer long-term complications your child will develop.

“The danger is that if GAD isn’t treated and kids don’t learn how to cope with anxiety in safe and effective ways, it can continue to erode their functioning,” Dr. Gerber says. “It really can become chronic and is a strong predictor of depression and other disorders later in life.”

Another real concern, particularly for adolescents and teens, is substance use.

“There are a lot of kids — when they haven’t gotten treatment — who will self-medicate and start drinking alcohol or smoking pot to ease their anxiety,” Dr. Gerber says. “But a lot of times, the opposite happens. It might be a relief initially, but if they don’t learn to cope with the discomfort and develop skills for dealing with their feelings, then the anxiety will continue to increase and often so will the substance use.”

Treatment options

Most instances of GAD can be treated with psychotherapy in the form of cognitive behavior therapy (CBT) or acceptance and commitment therapy (ACT).

With CBT, children and teens are taught their worries are not based in fact and learn ways to cope with anxious thoughts when they arise. Exposure therapy, a CBT technique commonly used in the treatment of anxiety, involves triggering a child’s anxiety a little at a time, in a safe and controlled setting, until the anxiety subsides. Once a child has learned to tolerate the anxiety without avoiding it, the anxiety diminishes.

There’s a limit to what you can do with exposure therapy for kids with GAD, who are worried about so many things, notes Dr. Bubrick. “You can’t do exposures for everything all the time. So, we do a lot of cognitive work instead. We do a lot of challenging thinking, getting kids to recognize that irrational thinking and replacing it with more logical, rational versions of those thoughts. So, it’s really having the kids learn a different way to think.”

Teens, particularly those who have prior experience with CBT, may benefit from ACT, a form of mindfulness therapy closely related to CBT. With ACT, a teen would learn to acknowledge and accept the anxious thoughts they’re having and commit to moving forward despite them. ACT helps kids step back and observe their anxiety, Dr. Gerber adds. “Rather than trying to stop it, they’re, in a way, making friends with it, treating it like an uninvited guest who’s tolerable, if not exactly welcome.”

Mild to moderate GAD can often be treated in anywhere from 10 and 20 therapy sessions. Severe GAD is treated with combination psychotherapy and medication for anxiety disorders , usually an antidepressant called an SSRI.

“The medication might allow them to progress more quickly in the therapy because they can tolerate the intensity of the worry or the anxiety better,” Dr. Gerber adds.

What parents can do

While GAD tends to run in families, it’s important not to blame yourself for your child’s anxiety and instead focus on helping them work past their worries.

“A lot of times parents will feel like they did something wrong,” Dr. Gerber says. “In reality, many factors go into a kid developing GAD. I like to tell them ‘You’re not the problem, but you can be a big part of the solution.’”

That involves getting your child the treatment they need and working with your child’s therapist to learn how to best support your child outside of the clinician’s office. Step one is to avoid inadvertently reinforcing anxious behavior. Parents can unintentionally accommodate fears by providing reassurance or allowing kids to avoid things that trigger their anxiety.

“It’s quite natural for parents to want to provide reassurance or accommodate a child when they’re upset,” Dr. Gerber says. “But by doing that, you’re sending the message that there is something to be worried about.”

As an example, Dr. Gerber says she once had a patient who was scared to come downstairs for fear something bad would happen. His well-meaning parents “got a mini fridge and plugged it in next to his room so he only had to peek out and grab a juice box when he wanted something to drink,” she says. “But that’s not helpful in the long run.”

On the other hand, it can be equally harmful to ignore or dismiss anxious thoughts since, “the more you try to avoid or accommodate anxiety, the stronger it gets,” Dr. Gerber says.

One relatively new approach to helping kids with GAD or other kinds of anxiety involves a therapist working with parents alone — not directly with the children. It’s called Supportive Parenting for Anxious Child Emotions , or SPACE, and it teaches parents how to change their own behavior in order to help their child overcome anxiety.

If parents have anxiety themselves, it can also help for them to get support or treatment, she adds. In turn, they’ll be better equipped to help their child with it as well.

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Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment.

July 2006, Vol. XXIII, No. 8

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Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment. 1-3 Family CBT (FCBT) has consistently yielded a high proportion of treatment responders (more than 70%) and in some studies has outperformed CBT programs with little family involvement. 3 This article presents the rationale supporting FCBT, provides a case study illustrating FCBT techniques, and summarizes the findings of a recent clinical trial.

RATIONALE SUPPORTING FCBT

FCBT for children’s anxiety disorders draws on effective cognitive-behavioral techniques 4 and supplements these with targeted family interventions . A good description of fundamental CBT techniques was published in 2003. 5 CBT for children’s anxiety disorders consists of 2 phases: skills training, and application and practice. During the skills training phase, children are taught techniques for reappraisal of feared situations, relaxation, and self-reward. In the application and practice phase, a hierarchy is created in which feared situations are ordered from least to most distressing. Children work their way up the hierarchy and are rewarded as they attempt increasingly fearful activities.

Seven studies have compared versions of FCBT with versions of child-focused CBT (CCBT) with little family involvement for children presenting with anxiety disorders . 3 Five of the studies have reported some outcome measures favoring FCBT over CCBT at the posttreatment assessment, whereas no outcome measures have favored CCBT over FCBT. In contrast, there were no differences found between the FCBT and CCBT programs studied, 6,7 and some longer-term outcome studies have suggested that differences between FCBT and CCBT lessen over the course of time. Nonetheless, the extant evidence suggests that there may be some advantage of the FCBT paradigm, particularly with regard to immediate effects.

Most FCBT programs have not focused on the specific parenting practices that are hypothesized to contribute to the development and maintenance of anxiety in children. In comparison, the FCBT program Building Confidence (J.J. Wood et al, unpublished manual, 2006) was developed by drawing on basic research in parent-child interaction patterns in families of children with anxiety disorders, 8,9 with the goal of enhancing treatment effectiveness. These studies suggest that high levels of parental intrusiveness and a lack of parent-granted autonomy are linked with anxiety disorders in children.

Parents who act intrusively tend to take over tasks that children are (or could be) doing independently and impose an immature level of functioning on their children. Among schoolaged children, parental intrusiveness can manifest in at least 3 domains: unnecessary assistance with children’s daily routines (eg, dressing), infantilizing behavior (eg, using baby words, excessive physical affection), and invasions of privacy (eg, parents opening doors without knocking). 10 Parents who act intrusively are posited to interfere with the process of habituation (fear reduction) by preventing children from actually confronting feared but benign stimuli. 9,11 Conversely, parents who grant appropriate levels of autonomy may enhance children’s feelings of mastery and self-efficacy, 12 and thus contribute to the regulation of anxiety.

The Building Confidence FCBT manual goes beyond previous CBT programs by directly intervening with parental intrusiveness and parentgranted autonomy. 10 The Building Confidence program includes individual sessions with the child and complementary parent-training sessions. These parent-training sessions emphasize:

• Giving choices when children are indecisive (rather than making choices for them).
• Allowing children to struggle and learn by trial and error rather than taking over tasks for them.
• Labeling and accepting children’s emotional responses (rather than criticizing them).
• Promoting children’s acquisition of novel self-help skills.

An incentive system is also taught to parents to encourage their children’s courageous behavior. A typical FCBT session begins with a 20-minute individual meeting with the child to conduct skills training or application/practice. Skills are reviewed less thoroughly with the child than in CCBT, permitting time for parent-training (20 minutes) and conjoint parent-child meetings (10 minutes). The following case describes a child with separation anxiety, but the issues it raises are also applicable to other types of anxiety disorders.

Ben is an 11-year-old boy living with his single mother in a semirural area of California. They share a small apartment with another single mother and her school-aged son. Ben’s mother works from home and their income is below the poverty line.

Ben is a slender boy with a friendly smile who is extremely nervous about being away from his mother, a behavior that meets the criteria for separation anxiety disorder. He has missed 20 days of school in the 2 months before intake because of reluctance to be away from home, has left school early 5 times because he felt “sick,” and frequently goes to the nurse’s office in school. His pediatrician has found no medical problem that would explain these difficulties.

Ben sleeps in his mother’s bed every night. He is distressed by worries about his mother being in a car accident while he is away from her, a concern not based on previous experience. Ben has avoided playdates, team sports, and afterschool activities because of separation anxiety, causing his mother to worry about his social development. Ben is exceptionally well-behaved and polite, and he has a precocious sense of humor. He noticeably perked up when interacting with male clinicians, flopping around the therapy room in mock slapstick routines or rushing to initiate conversation about topics he thought would be of interest.

There are numerous signs of intrusive parenting: Ben’s mother encourages his sleeping with her; she showers with him and washes his hair (an atypical scenario for an 11- year-old), she dresses and undresses him, and grooms his hair (which tangles easily and is difficult to manage) on a daily basis. Despite receiving assistance from his mother during these routines, Ben is actually capable of self-care in each of these areas. Ben also often sits on his mother’s lap, both he and his mother assert that all of these interactions help him feel less anxious.

FCBT USING THE BUILDING CONFIDENCE PROGRAM

The case study illustrates a typical pre-sentation of a child with separation anxiety disorder. 10 Commonly, as in Ben’s case, sexual abuse is screened for and ruled out; nonetheless, the intrusive interactions in question are developmentally inappropriate. In Ben’s case, the interactions appeared to be unintentionally reinforcing to his mother, since she indicated that she enjoyed being able to “be there for him and comfort him.”

Paradoxically, such comforting seems to support Ben’s separation anxiety rather than eradicate it. He feels dependent on his mother’s comforting for the regulation of his anxiety, and when he is away from her he finds it challenging to cope with the anxiety he experiences. Child psychiatrists and psychologists do not always screen for these kinds of intrusive parenting behaviors and, therefore, may be unaware of the role such behaviors play in the maintenance of anxiety disorders in children.

Skills training and focus on autonomy-granting

The first 4 sessions of FCBT focus on teaching core CBT skills, such as positive self-talk, and core parenting skills that can facilitate a child’s independence and self-confidence. Ben was exceptionally motivated, thrived on praise from his therapist, and made rapid progress in learning CBT skills. Coping skills that were emphasized included challenging Ben’s worries about his mother’s safety (eg, “My mom has never been in a car accident before, how likely would it be?”). However, Ben’s separation anxiety symptoms were slow to remit early in treatment. A major focus of parent training was increasing parentgranted autonomy and reducing intrusiveness. In talking with Ben’s mother, it was noted that children feel more confident when they do things for themselves that others have previously done for them and that this confidence can lead to courageous behavior.

Like many parents, Ben’s mother seemed to be caught between agreement (“He is very clingy,” she would acknowledge) and doubt (“He is only 11; can’t he still be a little boy?”). She emphasized that Ben’s clingy behaviors were not burdensome to her. To address her ambivalence, several techniques were employed:

• Empathizing with her desire to keep Ben close to her.
• Warning her that without him becoming a bit more independent, Ben’s maladaptive anxiety-related behaviors were likely to get worse.
• Offering a plan of action that emphasized gradual changes in parent-child interaction.

Parent communication skills, such as giving choices, as described above, were taught to Ben’s mother to support his development of autonomous behaviors. (Note that all parent-training activities in FCBT are directly related to 1 of 2 goals: altering the targeted parent-child interaction patterns or enhancing the child’s application/practice of CBT skills.)

Initial steps in increasing autonomygranting and reducing intrusiveness were selected by Ben, who noted that showering on his own and dressing himself would not be a problem as long as his mother was somewhere in the house. In a family meeting, Ben presented this to his mother and a plan was made to try it out. At the following session, Ben was praised for his followthrough. The therapist assessed the progress of these independent skills during each session, and Ben would flash an enormous smile, proudly affirming his mastery of the self-help tasks. Hair-brushing was added to the list, and when his mother could not tolerate his “lack of skill,” she simply gave him a shorter haircut that was largely maintenance- free-an excellent solution that supported Ben’s autonomy.

Ben’s mother-while not undermining these changes-did express sadness about his emerging independence. This reaction was normalized by the therapist (“All parents feel this way as their children become more mature”). Frequent reminders of the treatment rationale, and particularly the important role parents play in children’s anxiety reduction (by supporting their autonomy), were helpful in maintaining the mother-therapist alliance, as well as the changes in family routines that had been achieved.

Skills application and practice with parent support

A key tenet of FCBT is that early increases in parent-granted autonomy and independent child behaviors in sessions 1 through 4 pave the way for (a) increased self-confidence in the child, which facilitates the child’s engagement in facing feared situations in sessions 5 through 16 and (b) parental adoption of communication techniques (eg, giving choices) that enhance the effectiveness of the application and practice phase of CBT.

Ben’s first task in the application/practice phase was returning to school, and the timing of this coincided closely with his upsurge in self-confidence following the independent behavior sessions. Typical CBT techniques for addressing school refusal were employed, 13 and Ben stayed at school for longer and longer periods each day. Though predictably nervous, he tried his hardest, focused on challenging his fearful thoughts about his mother’s safety, and successfully ignored his anxious feelings (which were labeled “false alarms”). Incentives offered by his mother (eg, earning television time) also helped promote his adherence to the school-return plan.

Ben returned to school full time by session 10, evidencing habituation and a humorous “blas” attitude about his success. It is worth additional emphasis that the rapidity and ease with which full school return was accomplished was facilitated by Ben’s early self-confidence in the independent skills exercises and by his mother’s use of parenting skills to support his autonomy, both of which are FCBT-specific strategies.

Reducing cosleeping-a key goal in separation anxiety treatment-proved to be a formidable challenge. Ben agreed in principle by session 8 to sleep in his own bed on a nightly basis, but his mother was noncommittal. Ben’s anxiety was moderately high about sleeping independently even after the many successes he had achieved by midtreatment. Without his complete investment in this task, and with his mother’s reticence about changing their routine, treatment progress plateaued for several sessions (Ben’s mother said they had simply forgotten to have him sleep by himself).

Two shifts in the therapist’s approach proved critical. First, to increase the mother’s motivation, it was noted to her that full remission of separation anxiety rarely occurs unless children sleep on their own (which is true, in our clinical experience) and that excessive anxiety could ultimately interfere with Ben’s social and intellectual development. Second, to increase Ben’s motivation, a checklist was made of a number of highly feared tasks that when completed would lead to what he considered a large reward (a video his mother agreed to purchase for him). This checklist included Ben sleeping independently for 4 weeks in a row, inviting children from school over at least 4 times, and joining an after-school activity (choices were given).

Of course, Ben was given help in applying CBT skills in preparation for these activities. It was thought that by appealing to both Ben and his mother, chances for success would be doubled compared with relying on the solitary (and wavering) motivation of either of them alone.

This multifaceted approach proved effective. Ben’s mother was sufficiently persuaded by the therapist’s logic to permit a trial of the sleeping plan, while Ben was quite invested in his checklist incentive program and began sleeping independently. Within 2 weeks, Ben’s ratings on a 0-to-10 anxiety scale indicated that he felt no anxiety when sleeping by himself (again, reflecting habituation to a feared-but benign- situation). Simultaneously, he initiated playdates with a neighborhood boy that soon became reciprocal, and joined an after-school music program that he enjoyed. Ben’s mother was pleased with these accomplishments and began to praise the therapy program, including its emphasis on Ben’s independence. She voiced no further reservations about the new sleeping arrangements.

While still exhibiting a shy, eagerto- please disposition, Ben had no core anxiety disorder symptoms by session 16 when he was interviewed by an independent evaluator (using a structured diagnostic interview). Treatment gains were maintained at a 1-year follow-up interview

FINDINGS FROM A RECENT CLINICAL TRIAL

In a recent clinical trial, the Building Confidence FCBT program was compared with traditional CCBT with minimal family involvement. 3 Forty children with anxiety disorders (aged 6 through 13 years) were randomly assigned to FCBT or CCBT. Anxiety disorders (separation anxiety disorder, social phobia, and/or generalized anxiety disorder) were confirmed by an independent evaluator using a structured diagnostic interview. The 2 treatment conditions were matched for therapist contact time (12 to16 therapy sessions lasting 60 to 80 minutes each). Outcome measures included independent evaluators’ diagnoses, severity ratings for each diagnosis on the Clinician’s Rating Scale, 14 and improvement ratings on the Clinical Global Impressions (CGI) scale; child-reports on the Multidimensional Anxiety Scale for Children (MASC) 15 ; and parent reports on the MASC.

Overall, results favored FCBT over CCBT, highlights included:

• 79% of children in FCBT met CGI criteria for good treatment response, compared with only 26% of children in CCBT.
• Children in FCBT had greater improvement on independent evaluators’ ratings on the Clinician’s Rating Scale than children in CCBT.
• Parent reports of child anxiety on the MASC-but not children’s selfreports- were lower in FCBT than CCBT at posttreatment.

Although both treatment groups showed statistically significant improvement on all outcome measures, FCBT provided additional benefit over and above CCBT on most indices of improvement.

It should be noted that FCBT appears to be equally effective for children with primary diagnoses of separation anxiety disorder, social phobia, and generalized anxiety disorder. Although the case study presented above illustrates how FCBT can address separation anxiety, parental involvement is also beneficial for the treatment of the other 2 primary child anxiety disorder diagnoses. For example, parental intrusiveness is often seen in cases of children with social anxiety. Parents may offer excessive comfort when children are fearful in social situations and take over social tasks (eg, by speaking for their children) that children could handle independently. Variations of the FCBT techniques described above have proved helpful in addressing such family interaction patterns.

FCBT involves a complex interplay of cognitive-behavioral techniques and family restructuring, drawing on the combined (and sometimes complementary) resources and motivations of children and their parents. While CCBT is quite effective by itself, FCBT can lead to even greater improvements in anxiety, at least in the short term. 3 Therefore, it may be beneficial for clinicians to assess for parental intrusive-ness and autonomy-granting in cases of school-aged children with anxiety disorder and consider the use of a structured FCBT protocol that explicitly addresses such family dynamics when they are present.

Disclosures:

Dr Wood is an assistant professor of psychological studies in education in the department of education at the University of California, Los Angeles. His research focuses on the psychopathology of childhood anxiety, with an emphasis on randomized, controlled trials of cognitive- behavioral therapy interventions. The writing of this paper was supported, in part, by a grant from NIMH awarded to Dr Wood (MH075806). He reports that he has no conflicts of interest with the subject matter of this article.

References:

1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342. 2. Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consut Clin Psychol. 1998;66:893-905. 3. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006; 45:314-321. 4. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994;62:100-110. 5. Silverman WK. Using CBT in the treatment of social phobia, separation anxiety and GAD. Psychiatr Times. September 2003; Vol 20. 6. Nauta MH, Scholing A, Emmelkamp PM, Minderaa RB. Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of a cognitive parent training. J Am Acad Child Adolesc Psychiatry. 2003;42:1270-1278. 7. Spence SH, Donovan C, Brechman-Toussaint M. The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitivebehavioural intervention, with and without parental involvement. J Child Psychol Psychiatry. 2000;41: 713-726. 8. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39:1411-1427. 9. Rapee RM. The development of generalized anxiety. In:Vasey MW, Dadds MR, eds. The Developmental Psychopathology of Anxiety. New York: Oxford University Press; 2001. 10. Wood JJ. Parental intrusiveness and children’s separation anxiety in a clinical sample. Child Psychiatry Hum Dev. In press. 11. Fox NA, Henderson HA, Marshall PJ, et al. Behavioral inhibition: linking biology and behavior within a developmental framework. Annu Rev Psychol. 2005;56:235-262. 12. Chorpita BF, Barlow DH. The development of anxiety: the role of control in the early environment. Psychol Bull. 1998;124:3-21. 13. Kearney CA, Hugelshofer DS. Systemic and clinical strategies for preventing school refusal behavior in youth. J Cog Psychother. 2000;14:51-65. 14. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: Graywind; 1996. 15. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.

Evidence-based References

Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006;45:314-321

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Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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Physical Fitness Linked to Better Mental Health in Young People

A new study bolsters existing research suggesting that exercise can protect against anxiety, depression and attention challenges.

By Matt Richtel

Physical fitness among children and adolescents may protect against developing depressive symptoms, anxiety and attention deficit hyperactivity disorder, according to a study published on Monday in JAMA Pediatrics.

The study also found that better performance in cardiovascular activities, strength and muscular endurance were each associated with greater protection against such mental health conditions. The researchers deemed this linkage “dose-dependent,” suggesting that a child or adolescent who is more fit may be accordingly less likely to experience the onset of a mental health disorder.

These findings come amid a surge of mental health diagnoses among children and adolescents, in the United States and abroad, that have prompted efforts to understand and curb the problem.

The new study, conducted by researchers in Taiwan, compared data from two large data sets: the Taiwan National Student Fitness Tests, which measures student fitness performance in schools, and the National Insurance Research Databases, which records medical claims, diagnoses prescriptions and other medical information. The researchers did not have access to the students’ names but were able to use the anonymized data to compare the students’ physical fitness and mental health results.

The risk of mental health disorder was weighted against three metrics for physical fitness: cardio fitness, as measured by a student’s time in an 800-meter run; muscle endurance, indicated by the number of situps performed; and muscle power, measured by the standing broad jump.

Improved performance in each activity was linked with a lower risk of mental health disorder. For instance, a 30-second decrease in 800-meter time was associated, in girls, with a lower risk of anxiety, depression and A.D.H.D. In boys, it was associated with lower anxiety and risk of the disorder.

An increase of five situps per minute was associated with lower anxiety and risk of the disorder in boys, and with decreased risk of depression and anxiety in girls.

“These findings suggest the potential of cardiorespiratory and muscular fitness as protective factors in mitigating the onset of mental health disorders among children and adolescents,” the researchers wrote in the journal article.

Physical and mental health were already assumed to be linked , they added, but previous research had relied largely on questionnaires and self-reports, whereas the new study drew from independent assessments and objective standards.

The Big Picture

The surgeon general, Dr. Vivek H. Murthy, has called mental health “the defining public health crisis of our time,” and he has made adolescent mental health central to his mission. In 2021 he issued a rare public advisory on the topic. Statistics at the time revealed alarming trends: From 2001 to 2019, the suicide rate for Americans ages 10 to 19 rose 40 percent, and emergency visits related to self-harm rose 88 percent.

Some policymakers and researchers have blamed the sharp increase on the heavy use of social media, but research has been limited and the findings sometimes contradictory. Other experts theorize that heavy screen use has affected adolescent mental health by displacing sleep, exercise and in-person activity, all of which are considered vital to healthy development. The new study appeared to support the link between physical fitness and mental health.

“The finding underscores the need for further research into targeted physical fitness programs,” its authors concluded. Such programs, they added, “hold significant potential as primary preventative interventions against mental disorders in children and adolescents.”

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel

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A Multicenter Double-Blind, Placebo-Controlled Trial of Escitalopram in Children and Adolescents with Generalized Anxiety Disorder

Affiliations.

• 1 Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
• 2 Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
• 3 Division of Child & Adolescent Psychiatry and Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
• 4 Syneos Health, Morrisville, North Carolina, USA.
• 5 AbbVie, Lake Bluff, Illinois, USA.
• 6 AbbVie, Madison, New Jersey, USA.
• 7 University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
• 8 Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
• 9 Core Clinical Research, Everett, Washington, USA.
• PMID: 37074330
• DOI: 10.1089/cap.2023.0004

Objective: Generalized anxiety disorder (GAD) in children and adolescents is associated with substantial morbidity and increases the risk of future psychopathology. However, relatively few psychopharmacologic studies have examined treatments for GAD in pediatric populations, especially in prepubertal youth. Methods: Children and adolescents aged 7-17 years of age with a primary diagnosis of GAD were treated with flexibly dosed escitalopram (10-20 mg daily, n = 138) or placebo ( n = 137) for 8 weeks. Efficacy measures included the Pediatric Anxiety Rating Scale (PARS) for GAD, Clinical Global Impression of Severity (CGI-S) scale, Children's Global Assessment Scale (CGAS); safety measures included the Columbia-Suicide Severity Rating Scale (C-SSRS) as well as adverse events (AEs), vital signs, and electrocardiographic and laboratory monitoring. Results: Escitalopram was superior to placebo in reducing anxiety symptoms of GAD, as seen in the difference in mean change from baseline to week 8 on the PARS severity for GAD score (least squares mean difference = -1.42; p = 0.028). Functional improvement, as reflected by CGAS score, was numerically greater in escitalopram-treated patients compared with those receiving placebo ( p = 0.286), and discontinuation owing to AEs did not differ between the two groups. Vital signs, weight, laboratory, and electrocardiographic results were consistent with previous pediatric studies of escitalopram. Conclusions: Escitalopram reduced anxiety symptoms and was well tolerated in pediatric patients with GAD. These findings confirm earlier reports of escitalopram efficacy in adolescents aged 12-17 years and extend the safety and tolerability data to children with GAD aged 7-11 years. ClinicalTrials.gov Identifier: NCT03924323 .

Keywords: adolescents; children; escitalopram; generalized anxiety disorder; selective serotonin reuptake inhibitor; treatment.

Publication types

• Randomized Controlled Trial
• Multicenter Study
• Research Support, Non-U.S. Gov't
• Anxiety Disorders / diagnosis
• Anxiety Disorders / drug therapy
• Citalopram* / adverse effects
• Double-Blind Method
• Escitalopram*
• Nucleotidyltransferases / therapeutic use
• Treatment Outcome
• Escitalopram
• Nucleotidyltransferases

Associated data

• ClinicalTrials.gov/NCT03924323

Up to 40pc of mental health conditions are linked to child abuse and neglect, study finds

In 1996, Ange McAuley was just 11 years old when ABC's Four Corners profiled her family living on Brisbane's outskirts.

At the time her mother was pregnant with her sixth child and her father had long ago moved back to Perth.

WARNING: This story contains details that may be distressing to some readers.

It was a story about child protection and the program was profiling the role of community volunteers helping her mother, who had been in and out of mental health wards.

Ange was the eldest and it fell to her to get her younger siblings ready for school.

By the time the new baby arrived, she would stay home and change nappies.

"It was pretty crazy back then — I wasn't going to school a lot," she said.

By that age she was already holding a secret — she'd been sexually abused at age six by her stepfather, who would later be convicted of the crime.

"Back in the nineties, a lot of people kept stuff hidden and it wasn't spoken about outside of the family," she said.

"I've carried all these big burdens that weren't even mine. Sexual abuse happened to me. I didn't ask for it."

She says the trauma triggered a lifetime of mental health problems from substance abuse and self-harm as a teen, right through to post-natal depression.

Hidden source of our mental health crisis

A new study from the University of Sydney's Matilda Centre has established just how much Australia's mental health crisis can be traced back to this kind of childhood abuse and neglect.

The research has found that childhood maltreatment is responsible for up to 41 per cent of common mental health conditions including anxiety, depression, substance abuse, self-harm and suicide attempts.

The research, which draws on a 2023 meta-analysis of 34 research studies covering 54,000 people, found maltreatment accounted for 41 per cent of suicide attempts in Australia, 35 per cent of self-harm cases and 21 per cent of depression episodes.

It defined childhood maltreatment as physical, sexual, emotional abuse, emotional or physical neglect and domestic violence before the age of 18.

Lead researcher Lucy Grummitt said it is the first piece of work to quantify the direct impact of child abuse on long-term mental health. 

It found if childhood maltreatment was eradicated it would avert more than 1.8 million cases of depression, anxiety and substance use disorders.

"It shows just how many people in Australia are suffering from mental health conditions that are potentially preventable," she said.

Dr Grummitt said they found in the year 2023 child maltreatment in Australia accounted for 66,143 years of life lost and 118,493 years lived with disability because of the associated mental health conditions.

"We know that when a child is exposed to this level of stress or trauma, it does trigger a lot of changes in the brain and body," Dr Grummitt said.

"Things like altering the body's stress response will make a child hyper-vigilant to threat. It can lead to difficulties with emotion regulation, being able to cope with difficult emotions."

While some areas of maltreatment are trending down, figures from the landmark Australian child maltreatment study last year show rising rates of sexual abuse by adolescents and emotional abuse.

That study found more than one in three females and one in seven males aged 16 to 24 had experienced childhood sexual abuse.

Dr Grummit says childhood trauma can affect how the brain processes emotions once children become teens.

"It could be teenagers struggling to really cope with difficult emotions and certainly trauma can play a huge role in causing those difficult emotions," she said.

Mental health scars emerge early

For Ange, the trauma of her early years first showed itself in adolescence when she started acting out — she remembers punching walls and cars, binge drinking and using drugs.

"I would get angry and just scream," she said.

"I used to talk back to the teachers. I didn't finish school. Mum kicked me out a lot as a teenager. I was back and forth between mum and dad's."

By the time she disclosed her abuse, she was self-harming and at one point tried to take her own life.

"I was just done," she said.

"I was sick of having to get up every day. I didn't want to do it anymore."

Later on, she would have inappropriate relationships with much older men and suffered from depression, including post-natal depression.

"It's definitely affected relationships, it's affected my friendships, it's affected my intimate relationships," she said.

"Flashbacks can come in at the most inappropriate times — you're back in that moment and you feel guilt and shame.

"I feel like it's held me back a lot."

Calls for mental health 'immunisation'

Dr Grummitt said childhood abuse and neglect should be treated as a national public health priority.

In Australia, suicide is the leading cause of death for young people. 

"It's critical that we are investing in prevention rather than putting all our investments into treatment of mental health problems," she said.

Her team has suggested child development and mental health check-ins become a regular feature across a person's lifetime and have proposed a mental health "immunisation schedule".

Chief executive of mental health charity Prevention United, Stephen Carbone, said they estimate that less than 1 per cent of mental health funding goes toward prevention.

"There's been a big steady increase in per capita funding for mental health over the last 30 years but that hasn't translated into reductions," Dr Carbone, a GP, said. 

"You're not going to be able to prevent mental health conditions unless you start to tackle some of these big causes, in particular child maltreatment."

He said most of Australia's child protection system was about reacting to problems rather than trying to prevent them.

"If you're not tackling the upstream risk factors or putting in place protective factors you just keep getting more and more young people experiencing problems and services being overwhelmed," he said.

Now a mother of two teens herself, Ange says she wants to break the cycle and has been going to therapy regularly to help identify and avoid destructive patterns that she's seen herself fall into.

"I love my girls so much and I want better for them."

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