Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5541_Библиотеки_им_академика_М_И_Перельмана.pdf
204 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Box 11.1 Clinical Perspectives
Loneliness across Childhood and Adolescence
Loneliness is experienced by children, adolescents, and adults
across the lifespan. Loneliness is complex and involves aversive
emotions such as sadness or frustration coupled with a sense that
one is alone or disconnected from others. Varied types of loneliness
have been described, including intimate loneliness, the perceived
absence of someone with whom one can be oneself and experience
mutual connection and support; relational loneliness, the absence of
quality friendships or family connections; and collective loneliness,
the lack of a valued, shared social identity (Cacioppo et al., 2015).
Sources of loneliness include loss, absence, and physical distance.
The experience of loneliness peaks in adolescence (Qualter et al.,
2015). Chronic, prolonged loneliness is associated with significant
negative impact on well-being, relationships, and health.
For many youth, loneliness is transient. With a strong
need to affiliate with others, many children and adolescents
are motivated by the aversive experience of loneliness to seek
out and sustain social interactions and relationships (Qualter
et al., 2015). The qualities of positive relationships change
over time. “Children move from simply wanting to be
physically close to others to wanting close friendships that
are characterized by validation, understanding, selfdisclosure, and empathy” (Qualter et al., 2015, p. 252). Peer
rejection or isolation may lead to increases in loneliness. In
addition to a lack of social partners, believing that one has
undesirable social partners or is involved in harmful social
relationships contributes to increases in loneliness (Yang
et al., 2022).
The environments in which youth are embedded influence
loneliness. Cumulative support from parents, peers, and teachers
decreases loneliness (Cavanaugh & Buehler, 2016). The potential
negative impact of environments was especially evident during
the COVID-19 pandemic, which disrupted the social lives of
children and adolescents over several years. Increased rates of
loneliness, anxiety, and depression have been repeatedly observed
(e.g., Barbieri & Mercado, 2022). For youth with mental health
difficulties, the pandemic, with stay-at-home regulations and
school closures, amplified existing problems and increased the
risk for future problems (Hards et al., 2022; Loades et al., 2020).
Children and adolescents who report being lonely often
display negative cycles of isolation, negative social cognitions,
and increases in loneliness (Cacioppo et al., 2015). Negative
social cognitions include cognitive biases related to negative
self-evaluations and negative evaluations of others. These may
lead to hypervigilance to social threats and social withdrawal
that maintain the negative cycle. For children diagnosed with
anxiety disorders, social anxiety and other social information
processing factors may exacerbate these negative cycles (Maes et
al., 2019). Increasing social opportunities for lonely children is
usually not enough to effect positive change (Qualter et al.,
2015). Clinical interventions focused on cognitive bias are
designed to increase social motivation and develop social skills,
interrupt the negative cycle, and enhance social success (Eccles
& Qualter, 2021; Maes et al., 2019).
One last point: Children and adolescents report different
reasons for being alone. Not all children and adolescents who
spend time alone are lonely. Some choose to be alone, preferring
solitary play or solitude. This preference is not necessarily
problematic as long as they are able to engage socially when
asked or when they choose to be with others. As long as they are
not being rejected or rejecting others, for many youth (and
adults), time alone can be actively sought, satisfying, and
productive (Coplan et al., 2015).
Children and adolescents with OCD often request and
receive accommodations from parents and family members.
Over 95% of parents and families display some type of
accommodation (Kagan et al., 2018; Wu et al., 2019).
Accommodations may include verbal reassurance, help
and support (such opening doors so child can avoid dirt or
germs), participation in anxiety-related behavior (such as
checking daily weather reports with a child), and modifying
the environment or expectations to reduce anxiety (building
in more time in the morning schedule for checking rituals
before leaving for school). The more symptoms children or
adolescents display, and the greater the symptom severity,
the more likely it is that accommodations are made. These
accommodations are associated with poor outcomes such as
impairment at home and school.
Accommodation is similar in families of youth with
anxiety disorders and families of youth with OCD
(Lebowitz et al., 2014). Both mothers and fathers display
high frequencies of accommodation and accommodate
children in similar ways (Monzani et al., 2020). Irritability
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
and oppositionality in children and adolescents increase the
likelihood of accommodation (Wu et al., 2019).
Siblings, peers, and other adults such as teachers also
exhibit accommodation. School accommodations are a
complex phenomenon. Some accommodations are essential
and support achievement. Accommodations such as extended
time for testing for youth with ADHD are both reasonable
and legally mandated. Allowing a child or adolescent to
practice or present an oral report in front of the teacher
rather than in a large class is also reasonable. Exempting
youth from on-time arrivals or attendance requirements or
substituting written reports for all oral presentations are more
problematic. Well-intentioned accommodations by multiple
individuals in multiple settings may lead to the maintenance
or worsening of OCD or anxiety. “Helpful accommodations
should also be a moving target, removed when a youth no
longer needs them to be successful. The eventual removal
of such accommodations may be indicated for some youths.
Others may require additional strategies and supports
throughout their life” (Kagan et al., 2018, p. 230).
Etiology 205
Continuity and Course of Somatic
Symptom Disorders
Somatic symptom disorders interfere with individual, family,
peer, and school functioning (Garralda, 2010; Williams &
Zahka, 2017). One of the factors that appears to contribute
to ongoing difficulties involves the social consequences of
physical symptoms. For example, when children’s pain is
associated with positive attention and activity restriction,
symptom maintenance is more likely. Once established,
a somaticizing pattern is generally chronic and resistant
to both psychological and medical treatment (Walker
et al., 2012). Individuals with somatic symptom disorders
are subject to more frequent and more invasive medical
procedures, leading to increased medical costs and potential
medical problems. Children and adolescents with these
disorders are also at increased risk for other psychopathology
such as anxiety disorders and depressive disorders (Walker
et al., 2012; Williams & Zahka, 2017).
Etiology
Genes and Heredity
Genetics has a significant impact on the development of both
typical and pathological anxiety. Twin and family studies
have provided ample evidence that anxious parents are
more likely to have anxious children, and that monozygotic
twins are more similar to each other in terms of anxiety
than dizygotic twins (Iorfino et al., 2021; Lawrence et al.,
2019). As with so many other disorders, data suggest that
the genetic influence is the result of many genes, each with
a small effect. Genetic influences increase with age, and
the influence of shared environments decreases (Vasey et
al., 2014). For the most part, the genetic influence appears
to involve a general vulnerability rather than a disorderspecific risk (Lawrence et al., 2019). Genetic influences are
also significant for OCD (Arnold et al., 2018).
There are many anxiety-related investigations of geneby-environment-by-time (G 3 E 3 T) and epigenetic
processes. For example, some research suggests that
genetic effects on generalized anxiety disorder are
strongest for girls who experience frequent negative life
events (Vasey et al., 2014). Other research emphasizes
the impact of complex interactions among genetics,
individual differences in stress response patterns, the
timing and chronicity of adverse experiences, and
perceptions of control and uncontrollability (Smith &
Pollak, 2020).
An especially important finding involves the many
connections bet ween vulnerabilit y to anxiety-base d disorders
and vulnerability to depressive disorders. Over and over, the
data suggest a clear overlap between genetic inf luences on the
development of anxiety and the development of depression
(Hettema et al., 2019; Nivard et al., 2015). Children with
both of these internalizing disorders exhibit negative
emotion and emotion dysregulation. There are several
models that may explain the connections. First, the two
types of disorders may share the same underlying etiologies.
Second, there may be a temporal association, with anxiety
usually preceding depression. Third, anxiety and depression
may be distinct psychopathologies, each one increasing the
risk that the other will develop. Other explanations involve
specific environmental events that, coupled with underlying
vulnerability, lead to the expression of either anxiety or
depression (Hettema et al., 2019; Zavos et al., 2013).
These varied models of anxiety and depression
comorbidity are presented in Figure 11.3 (Cohen et al.,
2014). In both the causal model and the correlated liabilities
model, there are independent pathways to both anxiety and
depression. Evidence from a longitudinal study supports
the diathesis-anxiety model. In this model, children and
adolescents diagnosed with anxiety disorders go on to
develop depression “if they also tend to ruminate or be selfcritical” (Cohen et al., 2014, p. 26).
Figure 11.3 Three models for depression and anxiety in children and adolescents
Causal Model
Anxiety
symptoms
Source: Cohen et al. (2014). Why are anxiety and depressive symptoms comorbid in youth? A multi-wave, longitudinal examination of
competing etiological models.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Depressive
symptoms
Correlated Liabilities Model
Stressors
Cognitive
vulnerability
Depressive
symptoms
Anxiety
symptoms
Diathesis-Anxiety Model
Cognitive
vulnerability
Depressive
symptoms
Anxiety
symptoms
206 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Physiological Factors
Genetic predispositions to anxiety-based disorders involve
multiple mechanisms. Understanding neuroanatomy,
neurophysiology, and neurodevelopment are important
for explaining both typical and pathological anxiety.
Many investigations involve the study of the brain’s right
hemisphere, prefrontal cortex, and/or cerebellum. Given its
central role in the fear circuit and the processing of threat,
the limbic system, particularly the amygdala, is another
important research focus. There are extensive connections
between cortical regions and the amygdala that develop over
time, and amygdala dysfunction such as hyperactivation has
been repeatedly documented (Filippi et al., 2022; Zugman
et al., 2021).
Stress response systems, including the autonomic nervous
system and the hypothalamic-pituitary-adrenal (HPA) axis
system, are other contributors to risk (Smith & Pollak,
2020). Research on distributed brain circuitry, or brain
connectivity, with evidence of dysfunction across areas may
provide meaningful information about neurodevelopmental
risk (Zugman et al., 2021).
From the physiological perspective, then, hyperarousal,
heightened emotional responsivity, and dysregulation are
key contributors to increased risk for anxiety disorders,
with early adverse experiences increasing stress sensitivity
(Vasey et al., 2014). Other psychophysiological factors that
contribute to increased risk include perceptual sensitivity
to threat and attention biases toward threat (McLaughlin
et al., 2020). G 3 E 3 T research provides important
information about interactions between anxiety-related
psychophysiological processes and parenting (Buss & Qu,
2018; Morris et al.., 2017; Tan et al., 2020).
For OCD, research is focused on the atypical development
and function of the prefrontal-striatal circuits as well as
brain connectivity across regions (Bijanki et al., 2021; Kraper
et al., 2014). Certain infections may lead to pediatric
autoimmune neuropsychiatric disorder associated with
Streptococcus (PANDAS), an OCD-like presentation (Gilbert,
2019).
Child Factors
With the emphasis on arousal and dysregulation described
in the previous section, it makes sense that temperament
is one of the child variables that is associated with anxiety
disorders and OCD (Buss, 2011; Stifter & Dollar, 2016).
The temperamental trait most associated with anxiety is
inhibition. Inhibition involves a mix of wariness, arousal,
and emotional and behavioral preferences for any given
child (Buss & Qu, 2018; Fox et al., 2005). Many influential
investigations by Kagan and his colleagues describe children
at risk for later anxiety as both highly inhibited and highly
reactive (e.g., Kagan & Fox, 2006).
Inhibition influences anxiety problems in a number
of ways. In the diathesis-stress model, inhibition is a risk
factor that leads to wariness or fear in the presence of
environmental stressors. Inhibition or dysregulation may
also co-occur with other factors that lead to anxiety (such as
parental overprotection). Temperament characteristics and
anxiety may interact with one another in a negative cycle,
with heightened negative affectivity leading to increased
anxiety and increased anxiety further increasing already high
levels of inhibition, negative emotion, and dysregulation.
Temperament characteristics and anxiety may also share the
same underlying dimensions. These varied processes are not
mutually exclusive, and likely all of them contribute to the
multiple pathways to anxiety disorders (Buss & Qu, 2018;
Fillipi et al., 2022).
Emotion regulation (monitoring, moderating, and
enduring emotion) (ER) and emotion dysregulation also
contribute to the etiology of anxiety disorders (Beauchaine
& Cicchetti, 2019; Fox, 2018). Individual differences
in ER and dysregulation appear early and are stable over
time (McQuillan et al., 2018). As described previously, ER
strategies include acceptance of emotion experience, problem
solving, cognitive reappraisal, avoidance, suppression, and
rumination. The most helpful ER strategies (acceptance,
problem solving, reappraisal) are displayed less often in
youth diagnosed with anxiety. More problematic strategies
(avoidance, suppression, rumination) are displayed more
often (Schäfer et al., 2017).
The strategy of acceptance involves some degree
of distress tolerance (the perceived or actual ability to
tolerate negative emotion). Youth with low levels of
distress tolerance are less likely to view acceptance of the
negative emotion experience as a potential ER or coping
strategy. Indeed, distress intolerance is a transdiagnostic
risk factor that predicts increases in anxiety, depression,
and avoidance across development (Zvolensky et al.,
2010).
Anxiety sensitivity may further interfere with effective
emotion and behavioral regulation (Knapp et al., 2016;
Weems et al., 2010). To the extent that children and
adolescents are predisposed to immediately focus on and
overreact to uncomfortable body sensations, high levels of
anxiety sensitivity may be conceptualized as a diathesis.
Coupling this diathesis with significant or multiple stressors
may explain the development of panic disorder or somatic
symptom disorder in some youth.
Because effective ER develops over time and includes
repeated practice with varied emotion experiences and
varied strategies, children and adolescents who do not
practice with at least some of the helpful strategies are
unlikely to develop skilled ER. Emotion suppression
(concealing emotion experience) is a strategy with
emotional and social costs, including an increase in
anxiety symptoms (Gross & Cassidy, 2019). Individual
differences in emotion suppression are influenced
by neurodevelopment, family processes, and cultural
processes. Peers also provide signals about appropriate
or acceptable emotion expressions (Gross & Cassidy,
2019).
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Etiology 207
The influence of cognitive variables on the development
of anxiety disorders is also very salient. Cognitive and
attentional biases to perceive and attend more closely to
threatening stimuli, cognitive appraisals of ambiguous
situations as negative and threatening, specific cognitive
distortions related to the self (such as low self-efficacy),
and rumination all contribute to increased risk for anxiety
disorders (Schäfer et al., 2017; Songco et al., 2020; Vasey
et al., 2014). With respect to specific patterns of negative
cognitions and impaired decision making, combinations of
hypervigilance for threat and self-doubt lead to “a hesitant,
risk-averse, and self-deprecating decision-making style”
(Sonuga-Barke et al., 2016, p. 335). Broad impairments
in executive functioning may be especially important to
consider in children and adolescents with OCD (Snyder
et al., 2015).
Social information processing factors such as cognitive
biases and negative interpretations are associated with
heightened anxiety and avoidance of social interactions
and social situations (Nikolić, 2020). Difficulties with
social cognition, such as that observed with theory-of-mind
difficulties in youth with autism, are also associated with
social anxiety disorder (Pearcey et al., 2021).
Early experiences with control and lack of control may
contribute to a lack of security and a cognitive predisposition
to assume that one cannot control events or outcomes. This
predisposition underlies a sense of helplessness and increases
a child’s general vulnerability (Weems & Silverman, 2006).
Perceptions of controllability/uncontrollability influence
coping strategies and the development of internalizing
disorders (Compas et al., 2017). Adolescents’ use of
secondary control coping (acceptance, cognitive reappraisal)
is associated with fewer internalizing symptoms (Anderson
et al., 2021). Intolerance of uncertainty is also linked to high
levels of anxiety and worry (Osmanagaoglu et al., 2018).
A cognitive model of OCD describes several factors related
to dysfunctional beliefs and maladaptive interpretations of
intrusive thoughts (Cervin et al., 2022). These include: inflated
responsibility beliefs and heightened estimates of threat, thinking
one caused or influenced an event that is associated with
harm; perfectionism and intolerance of uncertainty associated
with checking, rituals, reassurance seeking; overimportance
and control of thoughts related to thought-action fusion, the
belief that thoughts and actions are equivalent (that having
a distressing thought is the same as engaging in distressing
behavior); and dysfunctional metacognitive beliefs or metaworry, which is the belief that worrying may help as well as
the belief that worrying makes things worse (Cervin et al.,
2022). Various patterns of these factors are observed in OCD
as well as in some anxiety disorders.
Behavioral models of risk and psychopathology emphasize
that children’s learning is at the root of anxiety. Rachman’s
(1977) theory of fear acquisition presented three pathways to
disorder: direct conditioning, modeling, and/or instruction
or information. There are data to support both direct and
indirect pathways (Rapee et al., 2009; Vasey et al., 2014).
Avoidance is frequently discussed in connection with
behavioral models. Avoidant behavior is associated with
decreases in distress. The short-term benefits associated
with decreased distress must be considered along with the
long-term consequences of maintaining and strengthening
escape and avoidant behavior related to fear and anxiety. If
avoidance is coupled with problem solving or when it allows
a child some space to settle down before re-engaging the
feared stimulus or situation, however, it may be a flexiblyused strategy. Maladaptation occurs when avoidance is
inflexible or unproductive (Hofmann & Hay, 2018).
Insecure attachments lead to both short- and long-term
outcomes involving anxiety disorders (Lewis-Morrarty
et al., 2015; Vasey et al., 2014). As summarized in
Chapter 5, the heightened risk involves not only more frequent
experiences of anxiety, but also difficulties engendered by
the caregiver’s problematic and often ineffective attempts to
manage the child’s wariness or distress. Although children
with histories of resistant attachment, avoidant attachment,
and disorganized attachment are all at increased risk,
children with disorganized attachments appear to be at
greatest risk. Clinical disorders are more likely when these
insecure attachment-related risks are combined with other
risk factors (Kerns & Brumariu, 2014).
Parent Factors
The family context in which children’s genetic inheritance
and psychological makeup is embedded is critical to the
development of anxiety-based disorders. The transactional
approach to psychopathology, discussed in many other
chapters, emphasizes the connections among child variables,
parent and relationship variables, and larger ethnic and
cultural variables. Parental psychopathology, including
anxiety disorders and OCD (as noted in the previous section
on genetics) is associated with increased vulnerability.
Multiple aspects of parenting have been identified as
risk factors including overcontrol, overprotection, and
overinvolvement (Creswell et al., 2020). Temperament
interacts with parental behaviors, with inhibited children
more likely to elicit overcontrol and overprotection (Bates
& McQuillan, 2019). Dysregulation also plays a role. The
more emotionally negative and dysregulated the child, the
more important positive parenting is (Morris et al., 2017).
Developmental status is another factor to consider. As young
children shift from co-regulation of difficult emotions to
a mix of co-regulation and independent regulation, how
parents respond to children’s distress is important (Compas
et al., 2017; Gross & Cassidy, 2019). Overall, parenting
behaviors that are problematic are those that decrease the
likelihood that children or adolescents will engage with
anxiety-eliciting stimuli and situations and develop effective
ER and coping strategies.
Parent fears and worries, modeling of avoidant behavior,
and accommodation of anxiety and avoidance are all related
to both the development and the maintenance of anxiety
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
208 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
disorders and OCD (Doom et al., 2021; Vasey et al., 2014).
Parents contribute to several anxiety trajectories. Parents
may socialize their children to view the world as dangerous
and children themselves as unable to cope. Anxious parents
may model anxiety and avoidance. Parents may respond
to child anxiety in ways that maintain or increase anxiety
and avoidance. These parenting factors may be more salient
for temperamentally sensitive or hypervigilant children
(Creswell et al., 2020; Vasey et al., 2014).
Individual and family dynamics are embedded into
particular cultural contexts, which help explain the
presentation, course, and treatment of anxiety disorders
(Doom et al., 2021). Even in communities and cultures where
parental control and involvement is more frequent and widely
accepted (such as in Latino families), control and involvement
are predictive of youth anxiety (Varela & Hensley-Maloney,
2009; Varela et al., 2013). In addition, culture-specific
inf luences have also been observed. Strict adherence to cultural
values emphasizing group harmony in Latino families, for
example, combined with low levels of emotion awareness in
youth, increases the risk for anxiety (Varela et al., 2019).
Environmental Factors
Adverse life events experienced by children also influence
risk and vulnerability. Loss of parents, parental divorce,
and maltreatment all increase the risk for the development
of anxiety disorders (Lawrence et al., 2019; Vasey et al.,
2014). Chronic stressors such as socioeconomic adversity,
discrimination, family problems, and friendship problems
have also been identified as contributing to the development
and stability of anxiety pathways (Doom et al., 2021; Kertz
et al., 2019). Reviews of investigations of environmental
risk factors for the etiology of OCD reveal few, if any,
environmental contributions (Brander et al., 2016).
Two examples of the impact of environmental stressors
on anxiety symptoms and trajectories involve exposure to
COVID-19 pandemic stress. In the first study, adolescents and
young adults displayed increased anxiety symptoms related to
the psychosocial effects of the pandemic (Kujuwa et al., 2020).
In the second study, a developmental pathway was described,
from behavioral inhibition in preschoolers to dysregulated
worry in adolescents to elevated and dysregulated anxiety in
young adults during the pandemic (Zeytinoglu et al., 2021).
Assessment and Diagnosis
There are two main tasks of assessment: (1) to determine
whether children’s anxiety reflects typical or atypical
adjustment, and (2) to discriminate among anxiety
disorders. Comprehensive assessment of anxiety disorders,
including interviews, self-reports, rating scales, physiological
assessments, and observations, is vital to evidence-based
clinical practice (Creswell et al., 2020; Hunsley & Mash,
2020). Anxiety questionnaires, such as t he Rev ised Children’s
Manifest Anxiety Scale (RCMAS) and the Screen for Child
Anxiety Related Disorders (SCARED), provide effective
general screening for anxiety disorders. Other measures,
such as the Multidimensional Anxiety Scale for Children
(MASC), help differentiate among specific anxiety disorders.
In addition, there are questionnaires that help clinicians
distinguish between internalizing disorders, including
anxiety and mood disorders (Fleischer et al., 2020).
For younger children, narrative stories may be used to
elicit anxiety themes (Warren et al., 2000). Parent and
teacher forms of anxiety rating scales are also used frequently
(Reardon et al., 2018). Parent attitudes and expectancies
can also be assessed (Eisen et al., 2004). A developmental
systems framework focused on child-family transactions
may be useful as well (Hunsley & Mash, 2020).
Even with abundant data, interpretation is often
difficult. That’s because agreement between children’s
reports and parents’ reports of anxiety symptoms and
avoidant behavior is usually poor (Hoffman & Chu, 2015;
Meiser-Stedman et al., 2007). Discrepancies among parent,
teacher, and clinician ratings of adolescent disorders have
also been reported, and these discrepancies are associated
with poor outcomes (Hoffman & Chu, 2015). Transgender
and gender-diverse youth, for example, report more severe
anxiety compared to their parents (in contrast to similar
ratings for depression (McGuire et al., 2021). Reasons for
the lack of agreement include children’s ability (or inability)
to describe their anxiety, children’s willingness (or lack of
willingness) to disclose their anxiety, parental awareness
(or lack of awareness), and parental distress. These reasons
underscore the need to gather data from both children
and parents and emphasize the need to increase parent
recognition of youth mental health difficulties (McGuire
et al., 2021; Youngstrom et al., 2003, 2004).
When an assessment for anxiety disorders involves youth
with other disorders such as those with autism spectrum
disorder, standardized instruments, especially self-report
measures, may provide less useful information. Psychologists
may rely more on observational methods along with parent
and teacher questionnaires for an accurate diagnosis (Kalvin
et al., 2020; Perihan et al., 2021).
Clinicians also need to take into account the cultural
backgrounds of children and their families, especially when
making decisions about internalizing disorders (Garralda &
Raynaud, 2008; Hunt, 2020). Finally, as with every disorder,
it is important to take into account a child’s strengths and
resources. These positive characteristics remind the clinician
(as well as parents and teachers) that children are more
than their disorders. Further, these positive characteristics
may be incorporated into a treatment plan that maximizes
therapeutic engagement.
Assessment and diagnosis of obsessive-compulsive
disorder, as with anxiety disorders, must take into account
typical development, such as the routines and rituals of
young school-aged children (Kraper et al., 2014). Structured
interviews and child and parent reports are all part of a
comprehensive clinical intake. Assessment of OCD severity
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Intervention 209
and impairment must be addressed. The Yale-Brown
Obsessive-Compulsive Scales (Y-BOCS) is a widely-used
questionnaire designed to rate symptom type and severity in
youth with OCD. Comorbid and differential diagnoses are
likely to focus on tic disorders, anxiety disorders, and autism
spectrum disorder (Lewin & Piacentini, 2010).
Perhaps more than any other physical or psychiatric
diagnosis, somatic symptom disorders require an integrated
approach involving combined medical and psychological
perspectives. The critical starting point is to rule out known
physical causes. In pediatric settings, high rates of medically
unexplained symptoms should prompt physicians to explore
internalizing psychopathologies (Agarwal et al., 2019). This
can then be followed by a consideration of how well the
symptoms meet the criteria for a somatic symptom disorder,
although it is again important to understand symptoms in
the context of culture.
Because the child, and often the family as well, have
a considerable psychological investment in the physical
symptoms, both are likely to respond with frustration and
even distrust when confronted by an inadequate medical
explanation. Also, these children and adolescents are,
by definition, resistant to an attribution that focuses on
emotional functioning. Consequently, they are unlikely
to accept a referral for psychological intervention. At least
for the more severe somatization cases, then, collaboration
between the psychologist and pediatrician is crucial.
Intervention
As with all psychopathologies, the prevention or reduction of
anxiety disorders is the goal of mental health professionals. A
number of prevention programs have demonstrated success,
and new ideas related to prevention are also promising (Palitz
et al., 2019; Vasey et al., 2014). These programs have been
implemented in preschools and elementary schools. One
relatively low-cost prevention program involves identifying
highly inhibited preschoolers in a day care setting and
providing a brief, six-session parenting intervention
designed to reduce anxiety disorders (Mihalopoulos et al.,
2015). When prevention is not possible, early interventions
become very important, not only for the immediate relief
of symptoms but also to reduce the risk of later disorders.
Early interventions for children with multiple phobias, for
example, may decrease overall risk for later internalizing
disorders and poor outcomes (de Vries et al., 2019).
The therapeutic alliance is an essential component of
all psychological interventions. It is especially critical in
psychological treatments for anxiety disorders, obsessivecompulsive disorder, and somatic symptom disorder. Children,
adolescents, and parents are participating in interventions that
require, at times, tolerance of increased distress and anxiety
before improvement occurs. A strong therapeutic alliance
ensures that children and adolescents understand the deep
concern the therapist has for their well-being and supports
ongoing engagement and effort across treatment sessions.
Pharmacological Treatment
Many effective treatments combine psychological and
pharmacological techniques, with anxiety medications
prescribed most frequently for children and adolescents
with anxiety disorders and obsessive-compulsive disorder
(Freeman et al., 2018; Norris & Kendall, 2021; Palitz
et al., 2019). Although research continues, these combined
therapies seem especially appropriate for older children and
those with more severe symptoms as well as for complex
cases that involve comorbidity. In the future, it is likely
that the recent growth in the pharmacological treatment of
anxiety disorders in young people will become more refined
due to the ongoing clinical trials of medications that include
children and adolescents.
Psychological Treatments
Given the nature of internalizing disorders, many children
and adolescents become the focus of intervention efforts
only after an anxiety disorder is firmly rooted. Many
others who struggle remain undiscovered and untreated.
Effective treatments for the wide range of anxiety disorders
are available (Baker et al., 2021; Comer et al., 2019; Zhou
et al., 2019). The treatment of choice is cognitive-behavioral
therapy. Cognitive-behavioral therapy (CBT) is based,
in large part, on the work of Phillip Kendall and his
colleagues (e.g., Albano & Kendall, 2002; Kendall, 2012)
and is associated with both immediate and long-term
improvements. Problematic beliefs, such as being unable to
cope with fear-eliciting threats or situations, are a key target
of CBT interventions. Behaviors associated with ongoing or
worsening anxiety such as avoidance are also intervention
targets. New learning experiences related to what happens
in anxiety-eliciting situations provide alternatives to
maladaptive patterns. Relaxation training is often an
important component of CBT.
The six main components of CBT are summarized in Table
11.5 (Velting et al., 2004). They are: (1) psychoeducation,
(2) somatic management, (3) cognitive restructuring, (4)
problem solving, (5) exposure, and (6) relapse prevention.
Psychoeducation involves providing children and their families
with information about typical anxiety and the emergence
and maintenance of pathological anxiety as well as about the
theoretical and practical aspects of CBT. Somatic management
involves targeting the distressing physiological symptoms and
is usually focused on relaxation and breathing techniques.
In addition, children and adolescents learn how to predict
and tolerate the anxiety that accompanies challenging and
stressful events. Cognitive restructuring has to do with the
identification and modification of negative thoughts that elicit
and prolong anxiety. Thinking about emotions and emotional
biases also may be important and is the focus of treatment
efforts in some instances. Problem solving is a step-by-step,
active, behaviorally oriented approach for coping. Exposure
to the stimuli and situations that are associated with anxiety
is systematic and controlled, with in vivo (real-life) practice
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
210 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Table 11.5 Main Components of Cognitive-Behavioral Therapy
Components Focus/Goals Associated Techniques
Psychoeducation
Somatic management
Cognitive restructuring
Problem solving
Exposure
Provide corrective information about the
nature of anxiety and feared stimuli
Target autonomic arousal and related
physiological symptoms, focus attention away
from anxiety-arousing physical sensations,
break the association between physiological
arousal and anxiety
Identify maladaptive (i.e., unhelpful)
thoughts, beliefs, and images, and teach
realistic, coping-focused thinking
Develop a variety of active methods for
coping with specific problem situations and
a system for testing the potential solutions
Graduated, systematic, and controlled
exposure to feared situations to provide
experience at using anxiety management
skills and consolidation of psychoeducation
material
Didactic instruction, self-monitoring
(diaries), and assigned reading
Breathing retraining (deep and slow
diaphragmatic breathing), relaxation
training (progressive muscle/applied
relaxation), meditation, and exercise
Monitoring of thought processes (diaries),
identification of automatic thoughts,
teaching rational disputation of automatic
thoughts, use of behavioral experiments
to gather evidence to refute automatic
thoughts, and use age-appropriate methods
for younger children
Identify the specific problem, generate
multiple alternative actions for improving
the situation, explore costs and benefits
of each potential solution, determine and
implement the preferred or most feasible
alternative, and evaluate outcomes
Behavioral exposure to feared situations,
interoceptive exposure to feared bodily
sensations (such as in panic disorder),
exposure should be direct (in vivo), but may
begin with imaginal or symbolic exposure
(e.g., use of photos of the feared object
instead of actual stimulus)
Relapse prevention
Source: Velting et al. (2004). Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents.
preferred. Relapse prevention involves laying the groundwork
for the maintenance and generalization of improvements.
Both individual and group formats do very well, with
approximately 60% of youth displaying positive outcomes.
Many children and adolescents display full recoveries
(Creswell et al., 2020; McKinnon et al., 2018; Warwick
et al., 2017). Sociodemographic variables such as age, sex/
gender, and race/ethnicity do not appear to influence
treatment outcomes. Research on comorbidity is mixed,
with some findings related to less positive treatment
response for youth with multiple diagnoses, while other
findings reveal similar treatment response (Norris &
Kendall, 2021). CBT is effective for youth with comorbid
autism spectrum disorder and anxiety disorder (Warwick
Focus on consolidating anxiety management
skills and generalizing treatment gains over
time, and decrease reliance on therapist and
others (e.g., parents) for managing anxiety
et al., 2017; Wood et al., 2020). In addition to the
anxiety disorders, empirical support has also been found
for psychological interventions such as CBT for somatic
symptom disorders (Bonvanie et al., 2017; Williams &
Zahka, 2017). Computer-based CBT is also effective for
many youth (Christ et al., 2020).
Cognitive control training (CCT) is focused on youths’
abilities to increase control over mental processes (shifting
attention and focus, inhibition of automatic responses).
The goals of CCT include direction of attention away from
emotionally-upsetting stimuli and better management of
cognition-emotion interactions. A review of CCT treatment
studies suggests that it is an effective anxiety-reduction
intervention.
Fading of sessions (from weekly to
biweekly), role reversal (child acts
as therapist for a session), videotape
commercial of therapy program, and
planned booster sessions
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Intervention 211
Internet-based treatments, with various educational and
experiential components presented in interactive formats,
have also been effective and are well received by both
children and parents (Lenhard et al., 2017; Nordh et al.,
2021). Because anxiety treatments are in high demand,
stepped-care treatment approaches may be used. All youth
needing treatment at a clinic, for example, may begin with
a computer-administered intervention. After completion,
those requiring more intensive help would be offered the
opportunity to step-up to individual CBT. This type
of approach is cost effective and increases the number of
children and adolescents who receive treatment (Yeguez
et al., 2020). Mental health monitoring apps for anxiety also
provide opportunities for increased engagement in treatment
for some youth. The ethical use of such apps requires careful
consideration (Williams & Pykett, 2022).
For children and adolescents whose anxiety has
interfered with the development of age-appropriate and
rewarding peer relationships, social skills interventions may
be especially important. School-based group interventions
provide opportunities for achieving anxiety- and peerrelated improvements (Haugland et al., 2020; Silverman et
al., 2019). Summer programs with camp-based activities are
another option (Santucci et al., 2015).
For children and adolescents with OCD, exposurebased CBT—exposure and response prevention (ERP)
treatments—are the standard evidence-based interventions
(Freeman et al., 2018; Metcalfe et al., 2022). ERP includes
gradual exposure to situations designed to provoke OCD
symptoms in a safe environment and under supportive
conditions coupled with the prevention of problematic
behaviors such as avoidance or rituals. The goal of ERP is
not to totally remove anxiety-eliciting situations, negative
thoughts, and compulsions but to develop greater distress
tolerance and coping skills in the face of them.
Acceptance and commitment therapy (ACT) emphasizes
mindfulness and focuses on the present moment and
acceptance of thoughts and feelings without judgment.
ACT has increasingly been incorporated into the treatment
of anxiety disorders as well as OCD (Twohig et al., 2018).
Given the salient role of the parents in etiology and
maintenance of anxiety disorders, OCD, and somatic
symptom disorders, it makes sense to work within a
treatment framework that incorporates family factors and
includes parents in treatment design and implementation
(de Barros et al., 2020; Cardy et al., 2020; Hulgaard et al.,
2019). It is also important to consider more general and
bidirectional cultural factors (Kendall, 2012). In particular,
treatments for anxiety disorders and OCD need to address
parent and family accommodation (Kagan et al., 2018).
Trajectories of decreasing accommodation predict better
outcomes (O’Connor et al., 2021).
Designing various treatments for several of the children
described earlier in the chapter provides examples of
these psychological treatments. To help Lakshmi with
her separation anxiety disorder and school refusal, it was
important to first clarify for her parents and family that
it was not school that was upsetting Lakshmi. Rather,
anxiety about separating from her mother was interfering
with her entry into first grade. Consequently, intervention
efforts were aimed at restoring Lakshmi’s confidence in
her relationship with her mother as well as her own selfconfidence. To help with the transition to a calmer start to
the school day, a picture of her mother was taped to the
inside of her desk as a reminder that her mother was fine and
would be waiting for her at home at the end of the day. For
several days, Lakshmi was also allowed to call her mother
after lunch if she wished. By the end of four weeks of these
efforts, Lakshmi was again looking forward to her school
day and separated from her mother easily in the morning.
For Jack’s weather phobia, any of four classic
behavioral treatments for fears (or combinations of these
treatments) might be used, including modeling, systematic
desensitization, reinforced exposure, and self-talk (Weisz,
2004), with attention paid to the individual response pattern
and developmental status. Modeling treatments are based
on the impact of observational learning. With this approach,
Jack might participate in symbolic modeling (using videos
of children displaying nonfearful behavior during bad
weather), live modeling (using in-person observation
of nonfearful children playing outside in the rain), or
participant modeling (pairing Jack with a nonfearful child).
Depending on the child, modeling treatments may achieve
good outcomes quite quickly. Systematic desensitization
involves teaching an anxious child how to relax and how to
maintain relaxation when exposed to the feared stimulus.
Exposure is done gradually (i.e., systematically, from
watching clouds and rain showers on videos, to watching
actual storm clouds and rain from inside the home, to going
on drives with a parent during a rainstorm), building on the
child’s successes over time. Exposure involves rewarding a
child for desired behavior. In Jack’s case, he might receive
tokens for more functional weather-related behaviors. Self-
talk is a cognitive technique focused on providing positive
self-statements such as “I am brave,” to enhance appropriate
behaviors. All these treatment approaches depend on
establishing a trusting relationship with a therapist because
children need to believe (and feel deep down) that this adult
will keep them safe.
Charlotte, the girl diagnosed with generalized anxiety
disorder, needed to spend several sessions becoming
accustomed to, and comfor table with, the therapeutic setti ng,
the therapist, and the therapeutic relationship. Charlotte
and her parents discussed the age-related expectations and
tasks that were important to her and the ways that it would
be advantageous (and even fun) to meet them. She spent
many of the sessions engaged in role playing and practicing
self-talk strategies that would help her manage her base
levels of anxiety and her specific anxiety symptoms.
Asher, diagnosed with autism spectrum disorder and
generalized anxiety disorder, received more specialized
support in school settings. The school psychologist and
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
212 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Asher’s teachers more effectively identified anxiety triggers
and early signs of Asher’s distress. A new behavioral plan
was developed to clearly signal upcoming transitions and
reward Asher for verbalizing thoughts and feelings. Asher’s
teachers and parents collaborated to help Asher develop
new ways of coping with increases in anxiety. The school
psychologist also made a referral to a community therapist
experienced in working with ASD youth and their families.
This therapist worked with Asher and his parents using a
CBT approach adapted for higher functioning autistic
youth that focused on the identification and differentiation
of emotions combined with anxiety management techniques
such as deep breathing and relaxation.
Daniel, diagnosed with OCD, received an intervention
that first involved education for him and his parents about
the disorder. During these discussions, Daniel’s father also
revealed that he also had experienced a variety of significant
anxiety symptoms, including some sub-clinical obsessivecompulsive behaviors. A cognitive-behavioral treatment
plan was developed, and a referral for a medication
consultation was made. Cognitive techniques were used
to identify patterns of thoughts and behaviors that had
become maladaptive, and new, more effective strategies
for dealing with anxiety were developed. Behavioral plans
to limit compulsive behaviors were also created, including
techniques that exposed Daniel to triggering stimuli while
preventing the compulsive response. In this way, he became
desensitized to anxiety-provoking stimuli and no longer felt
the urgent need to engage in the compulsive behaviors.
After several meetings with Isabella and her parents, the
hospital team working with her diagnosed a somatoform
pain disorder. In discussing this with Isabella and her
parents, it was emphasized that no one thought that she
was faking. Rather, the facts that Isabella very much wanted
to do well in high school and also please her parents were
noted, and the suggestion was made that although Isabella
was not feeling directly anxious about this, the pressure to
perform had begun to interfere with her ability to manage
her daily demands. As part of this suggestion, the therapist
mentioned that there were many ways in which bodies and
minds work together, in both positive and negative ways. A
plan was developed with input from the family, physician,
and psychologist in which medical monitoring would be
combined with help from the psychologist a s Isabella returned
to school. It was emphasized that although they would
continue to investigate physiological factors, the most truly
dangerous possibilities had already been ruled out, and it was
medically safe for Isabella to return to school. Gradually, the
psychologist helping her became more involved in coaching
her to develop more adaptive and effective ways of managing
stress in her life. Mind–body pain management strategies
were an important component of ongoing treatment.
Key Terms
Distress tolerance (193)
Fears (194)
Worries (194)
Anxiety disorders (195)
Anxiety sensitivity (195)
Separation anxiety disorder (SAD) (195)
Phobic disorders (197)
Specific phobias (197)
Social anxiety disorder (197)
Agoraphobia (197)
Generalized anxiety disorder (GAD) (199)
Panic disorder (200)
Chapter Summary
●
Fears and worries are typical and expected parts of
childhood and adolescence. When they consistently
interfere with healthy development, an anxiety disorder
may be present.
●
Emotional experiences, including emotion regulation
(ER), follow a developmental course that must be
considered when determining whether typical anxiety
crosses over to pathological anxiety.
Obsessive-compulsive disorder (OCD) (201)
Obsessions (201)
Compulsions (201)
Somatization (202)
Somatic symptom disorders (202)
Conversion disorder (functional neurological symptom
disorder) (202)
Accommodation (203)
Cognitive-behavioral therapy (CBT) (209)
Cognitive control training (CCT) (210)
Modeling (211)
Systematic desensitization (211)
Exposure (211)
Self-talk (211)
●
Anxiety disorders represent the maladaptive experience of
anxiety in terms of intensity, duration, and pervasiveness.
They are also characterized by inhibition and withdrawal,
exaggerated and unrealistic fears and worries, and
overcontrol. Avoidant behavior is frequently part of the
clinical presentation.
●
Anxiety disorders are among the most frequently
diagnosed disorders in children, adolescents, and adults.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Intervention 213
●
Some of these disorders, such as generalized anxiety
disorder, represent an anxious reaction to a wide array of
stimuli, while others, such as separation anxiety disorder
and specific phobias, are rooted in more specific anxietyproducing situations.
●
Obsessive-compulsive disorder involves obsessions
(persistent, intrusive, and negative thoughts or images)
coupled with compulsions (impulses or ritualized
behaviors). Clinical presentations are varied.
●
Somatic symptom disorders involve the experience of
physical symptoms that appear related to the moderation
of emotions, especially anxiety. Anxiety sensitivity is
often exhibited.
●
Genetic and other physiological risk factors are clearly
linked to the development of anxiety disorders. Research
suggests that anxiety and mood disorders result from
closely related risk factors.
●
Child factors related to increased risk include behavioral
inhibition, emotion dysregulation, and varied cognitive
factors.
●
Parenting behaviors that may potentially contribute
to the development of anxiety disorders include an
anxious style of parenting, such as overinvolvement and
overprotection, as well as the modeling of anxious and
avoidant behavior. Accommodation is associated with
the maintenance of symptoms and worse outcomes.
●
Comprehensive assessments, i ncludi ng clinical i nter views,
self-report measures, and clinical observations, are used
to differentiate typical from pathological levels of anxiety
and to discriminate among anxiety disorders.
●
A variety of psychological interventions (cognitivebehavioral therapy in particular), often in combination
with pharmacological approaches, have proven effective
in the treatment of anxiety disorders.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.