How can we treat global anxiety problems? - Chapter 15

What is this chapter about?

Anxiety disorders are the most common type of disorder that affects children and adolescents. Between 2.5% and 5% of children meet the diagnostic criteria at any given time. Anxiety disorders are associated with poor relationships with peers, increased victimhood, poor academic achievements, and disrupted family processes. The three most common anxiety disorders in children are separation anxiety disorder (SAD), social phobia, and generalized anxiety disorder (GAD). Comorbidity between these disorders is high and they are often treated in a similar way.

What is a separation anxiety disorder (SAD)?

Separation anxiety disorder (SAD) refers to a huge fear of being separated from home or from others to whom the child is attached, mainly the parents (and especially the mother). The fear can arise when the child is only a few minutes away from his mother, or after being separated for a week. Children with SAD are afraid that something will happen to them or their mother during the period when they are separated.

What does social phobia mean?

In social phobia, there is fear about possible negative evaluation of others, which makes the child feel humiliated or ashamed. As a result, these children are afraid of many social situations and find it hard to make new friends. However, these children do have the need for good quality relationships with others.

What is a generalized anxiety disorder?

Unlike the two previous anxiety disorders, a generalized anxiety disorder (GAD) is not a specific anxiety disorder, but rather a general anxiety disorder. A child with GAD experiences fear about many events and activities. In addition, a child GAD must meet one of a ‘physical symptom’, such as difficulty sleeping, restlessness, or muscle tension. Children with GAD often exhibit subtle avoidance behavior.

What is the treatment program?

There are many CBT programs for anxiety disorders. Core components of all treatments are cognitive restructuring, gradual exposure, and training for parents. Additional components include training in assertiveness, social skills, and problem-solving skills. In addition to verbal instructions, techniques and activities such as role-playing are included. Homework also plays an important role in the treatment process.

Anxious children often turn their attention to threatening things and they are quick to interpret ambiguous situations in a negative or threatening way (cognitive bias). CBT helps to come up with alternative interpretations and focus on non-threatening stimuli in the environment. The gradual exposure is used to gradually allow the child to enter their feared situations, so that accurate and realistic information about this (hitherto avoided) situation and about their (possibly adequate) coping skills can be obtained. Training for parents is necessary, because they are very often far too involved with their anxious child, which makes the child more dependent on their parents and maintains their avoidance behaviour.

An example of a CBT family program is "Cool Kids" (for families with children between 7 and 16 years). This treatment consists of ten 2-hour sessions (1 session per week) and consists of the above core components and additional components. If the child is 12 years of age or younger, the parents must attend each session. The program can be given to just one family family, or in a group with four to eight families in which the children are about the same age. The program consists of five components:

1. Psycho-education (session 1) on anxiety disorders in children, and explanation of treatment. The link between feelings and thoughts is explained to the child. Parents learn the causes and nature of anxiety disorders in children.
2. Cognitive restructuring (session 2 and 3). During these sessions, the concept of cognitive restructuring is introduced and focuses on different strategies to address (and refute) incorrect, inappropriate thoughts.
3. Parenting and rewards (session 3): Parents are taught new strategies to deal with their child's anxiety (increase their child's independence, encourage positive behaviors, reduce the extent to which the child seeks reassurance). Children are taught to reward themselves.
4. Gradual exposure or response prevention (session 4 to 6) on the basis of a jointly drawn and climbed hierarchical ladder (from a situation that evokes little fear to the situation that evokes the most fear).
5. Stimulating and maintaining the acquired skills above, and acquiring additional skills (session 7 through 10).

What is the effectiveness of CBT for anxiety disorders?

There is a lot of supporting evidence for the effectiveness of CBT in anxiety disorders in children and adolescents. Most of the studies focus on anxiety disorder as a whole (SAD, social phobia, GAD and other anxiety disorders such as a specific phobia). Due to the great heterogeneity of people with anxiety disorders, there is little evidence for the effectiveness of CBT for specific types of anxiety disorders. In addition, there is always a minority of children who still meet the criteria of an anxiety disorder after treatment, which requires more research about how this is possible.

What are new perspectives on treatment of anxiety?

Due to developments in neuroscience, there are additional interventions developed that can contribute to a positive outcome of treatment. A partial agonist of the NMDA receptor is called DCS (d-cycloserine). DCS improves the learning process during exposure therapy and facilitates the learning process for safe signals. In addition, it is not an anxiolytic (so DCS has no bad side effects, such as numbness and dizziness, in comparison with traditional medications). However, more research is needed into the effectiveness of DCS.

Family-related risk factors also play a major role in the outcomes of treatment, as the prevalence of anxiety disorders in the parents of anxious children is high: two-thirds of mothers seeking help for their child also have an anxiety disorder themselves (Last and colleagues, 1987). Left untreated, this may hinder the treatment of the child. Anxiety management for the parent(s), in addition to child-focused CBT, is therefore very important and promising for increasing the effectiveness of the treatment. However, several studies show that reduction of parental anxiety (with the help of a program called PAM – parental anxiety management) does not necessarily change the behavior of the parents, and this behavior often maintains the child's anxiety problems (such as parental overinvolvement). Reducing the anxiety of the parent(s) may therefore be insufficient: PAM will also need to incorporate modules that address and minimize negative behaviours.

A third and final route that can be taken to increase the effectiveness of anxiety treatments in children and adolescents lies in the genetic predictors of the response to treatment. Children with the short, (S) variation of the 5HTTLPR (as opposed to the long, so-called (L) variation of this gene) react worse to negative environments and more positively to positive environments. In other words: these children are more sensitive to their environment. In this way, genetic information can be used as a means to compose the treatment.

Anxiety disorders are the most common type of disorder that affects children and adolescents. Between 2.5% and 5% of children meet the diagnostic criteria at any given time. Anxiety disorders are associated with poor relationships with peers, increased victimhood, poor academic achievements, and disrupted family processes. The three most common anxiety disorders in children are separation anxiety disorder (SAD), social phobia, and generalized anxiety disorder (GAD). Comorbidity between these disorders is high and they are often treated in a similar way.