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Anxiety Disorders in

Children and Adolescents

Jess P. Shatkin, MD, MPH

Vice Chair for Education
NYU Child Study Center
New York University School of Medicine
Learning Objectives
Residents will be able to:
1) Identify the primary anxiety disorders in
2) Distinguish between developmentally
“normal” anxiety and pathological anxiety
3) Describe the clinical presentation,
epidemiology, etiology, diagnosis and
treatment of the major childhood anxiety
What is Normal?
10 – 20% of children and adolescents suffer a diagnosable anxiety
Many more children suffer with symptoms that do not meet diagnostic
criteria (Walkup et al, 2008)
~40% of grade school children have fears of separation from a parent
~40% of children aged 6 – 12 years have 7 or more fears that they find
~30% of children worry about their competence and require considerable
~20% of grade school children are fearful of heights, are shy in new
situations, or are anxious about public speaking and social acceptance
(Bell-Dolan et al, 1990)
Girls report more stress than boys – may be an artifact of social
Most of these worries and stresses are outgrown or recede as children
mature and develop
Anxiety can be your friend
Distinguishing Normal
from Pathological
1. Object: Is this something a child of this age should be
worrying about?
2. Intensity: Is the degree of distress unrealistic given the
child’s developmental stage and the object/event?
3. Impairment: Does the distress interfere with the child’s
daily life?
- Social functioning: unable to make friends
- Academic functioning: failing classes
- Family functioning: creating conflicts, limiting family
4. Ability to Recover/Coping Skills: Is the child able to
recover from distress when the event is not present?
- Tend to worry about future occurrences of event/object
- Distress occurs across multiple settings
Normal Fear and Worry
Common in normal children
The clinician must distinguish
developmentally normal from abnormal
– Fear of loud noises
– Fear of being startled
– Fear of strangers (around 8 – 10 months)
Normal Fear and Worry (2)
– Fears of imaginary creatures
– Fears of darkness
– Normative separation anxiety
School-age Children
– Worries about injury and natural events (e.g., storms,
lightening, earthquakes, volcanoes)
– Children who are characterized as confident and eager to
explore novel situations at 5 years are less likely to
manifest anxiety in childhood and adolescence
– Children who are passive, shy, fearful, and avoid new
situations at 3 and 5 years are more likely to exhibit
anxiety later in life (Caspi et al, 1995)
Normal Fear and Worry (3)
School Age Children (continued)
– In general, girls tend to endorse more anxiety
symptoms than boys
– Younger children are more likely to experience
anxiety symptoms than older children
– Anxious children interpret ambiguous situations in
a negative way and may underestimate their
competencies (attribution bias)
– The most common anxiety disorders in middle
childhood are Separation Anxiety, GAD, and
Specific Phobias
Normal Fear and Worry (4)

– Fears related to school
– Fears related to social competence
– Fears related to health issues
Clinical Presentation
Children with anxiety disorders may present with
fear or worry but may not recognize their fears as
Younger kids often cannot articulate their feelings,
and so we often see physical symptoms
presenting first, which include:
– Headaches, upset stomach or nausea, increased heart
rate, diarrhea or constipation, sleep disturbance,
increased vulnerability to common viruses, tightness in
chest, tight neck or back, appetite change, fatigue &
What To Look For
Physical complaints (H/A, GI, dramatic)
Sleep (early/middle insomnia, repeated visits to parent ’s
Change in eating
Avoidance of outside and interpersonal activities
(school, parties, camp, slumber parties, safe strangers)
Excessive need for reassurance (new situations,
bedtime, school, storms, “is it bad?”)
Inattention and poor school performance
Not necessarily pervasive (some areas of function
remain intact)
Explosive outbursts
Physical Symptoms (Provoked and
Anxious children listen to their bodies (too much!)
Headache & stomachache
Sick in the morning
Frequent urge to urinate or defecate
Shortness of breath
Chest pain, tachycardia
Sensitive gag reflex/fear of choking or vomiting
Difficulty swallowing solid foods
Avoidance to present physical symptoms
Clinical Presentation:
Separation Anxiety Disorder
Excessive fear when separated from home or attachment
Can be seen before separation or during attempts at
Excessive worry about their own or their parents’ safety and
health when separated
Symptoms include difficulty sleeping alone, nightmares with
themes of separation, somatic complaints, school refusal
Commonly, the earliest age of onset among anxiety
Gender ratios are generally equal
These children often come from singe-parent and low SES
A nonspecific precursor to a number of adult psychiatric
conditions, including depression as well as any anxiety d/o
Clinical Presentation:
Fear of a particular object or situation which
is avoided or endured with great distress
More than one phobia is common (does not
in and of itself constitute a diagnosis of GAD)
Adolescents and adults typically recognize
that the fear is unreasonable; children often
do not
Avoidance is key
Generally begins in childhood
Clinical Presentation:
Generalized Anxiety Disorder
Characterized by chronic, excessive worry in a
number of areas (e.g., schoolwork, social
interactions, family, health/safety, world events, and
natural disasters) with at least one associated
somatic symptom
Affected children are often perfectionistic, seek
reassurance, and struggle more than is evident to
parents and teachers
Worry is most often present and not limited to a
specific situation or object
These kids don’t just worry about performance and
social concerns (e.g., social phobia) – these kids
worry about the quality of their relationships rather
than experiencing embarrassment or humiliation in
social situations
Clinical Presentation: Social Phobia
Characterized by feeling scared or uncomfortable in one or
more social settings (discomfort with unfamiliar peers and
not just unfamiliar adults) or performance situations (e.g.,
sports, music)
Associated with a fear of scrutiny and of doing something
embarrassing in social settings such as classrooms,
restaurants, or extracurricular activities
May have difficulty answering questions in class, reading
aloud, initiating conversation, talking with unfamiliar people,
and attending parties and social events
The anxiety with social phobia dissipates when away from a
social situation; unlike GAD where the anxiety is persistent
90% of children with Selective Mutism have been shown to
meet criteria for Social Phobia (SM should probably be
viewed as a specific type of Social Phobia)
Differential with PDD
Clinical Presentation:
Panic Disorder
Recurrent episodes of intense fear that occur
unexpectedly (cued or uncued)
Panic disorder vs. panic attacks
Cued panic attacks can occur with any anxiety
disorder, or independently, and are common among
Fear of death or going crazy
Uncommon before the peri-pubertal period (adult
retrospective studies have shown that sx commonly
begin in adolescence or young adulthood)
The peak age of onset of panic d/o is age 15 – 19
Clinical Presentation:
Obsessive-Compulsive Disorder
Most patients experience both obsessions
and compulsions
Changes in symptoms and in intensity over
Parents often become unwilling collaborators
in the illness
Symptoms commonly exist for years before
reaching clinical attention
Any or all anxiety symptoms
Symptoms may wax and wane
Symptoms typically worsen when
confronted with reminders or situations
reminiscent of the trauma
Behavioral Inhibition
Learned Responses
Attachment Research
Behavioral Inhibition
“Behavioral Inhibition” (a lab-based
temperamental construct) is defined as the
tendency to be unusually withdrawn or timid and to
show fear and withdrawal in novel and/or
unfamiliar social and nonsocial situations
Those who are withdrawn in social situations only
are considered “shy”
Both behavioral inhibition and shyness are
associated with anxiety disorders in both children
and adults
The tendency to approach or withdraw from
novelty is an enduring temperamental trait
Behavioral Inhibition (2)
Kids with BI show a lot of physiological signs often
associated with anxiety, including enhanced sympathetic
nervous system tone (e.g., elevated resting heart rate and
salivary cortisol), increased tension in the vocal cords and
larynx, and elevations in urinary catecholamines (Kagan et
al, 1988)
Kids with BI are more likely to have multiple psychiatric
disorders and two or more anxiety disorders (especially
Avoidant D/O, Separation Anxiety D/O, and Agoraphobia)
Kids with BI have a higher risk of panic is they age (Smoller
et al, 2005)
Thus, Behavioral Inhibition is a risk factor for the
development of anxiety disorders in children
BI is also heritable
Neurobiology of Anxiety
Systems involved in sensing and responding
to threat are redundant and involve numerous
brain systems to promote survival
Reticular Activating System (a network of
ascending, arousal-related neural systems)
– Locus coeruleus NA mobilizes in response to real
or perceived threat
– Dorsal raphe 5HT mediates the locus coeruleus
– Lateral dorsal tegmentum cholinergic & mesolimbic
& mesocortical DA neurons affect brain sensitivity
and interpretation of threat
Limbic System (1)
Anxiety is believed to recognized at the amygdala
The hippocampus is the storage site of cognitive
and emotional memories and is very sensitive to
Threat alters the ability of the hippocampus and
connected cortical areas to store certain types of
cognitive information (verbal) but not nonverbal
Many of the cognitive distortions that are associated
with anxiety disorders may be related to anxiety
related alterations in the tone of the hippocampus
and associated cortical areas
Limbic System (2)
Neuronal systems are capable of making
remarkably strong associations between
paired cues (e.g., growl of a tiger and threat)
This capacity of the brain to generalize from a
specific event renders humans vulnerable to
false associations and over generalizations
Once these specific cues (e.g., snakes)
become linked with limbic mediated
responses (e.g., anxiety), it is the sensitivity of
the individual’s stress response system which
determines if the alarm system (anxiety) will
be activated
Genetics of Anxiety
There are thousands of genes which, if abnormal, could
result in altered development or functioning of
neurotransmitter and neuroanatomical regions involved in
regulating anxiety
Strong familial trends in anxiety disorders
No clear data support a specific genetic etiology for
childhood anxiety disorders
Heritability estimates of Panic Disorder (48%) and
Generalized Anxiety Disorder (32%) exist (Hettema et al,
Given these estimates, it is clear that genes account for only
some portion of the increase in risk among family members
of an affected individual
Environmental factors (e.g., perinatal exposures and
developmental experience) must play a major role
Learned Responses
Most specific fears (phobias) are related to paired or
mispaired internalization of cues with anxiety from
previous experience
Some anxieties may involve genetically fixed
patterns developed over eons of evolution (e.g.,
During infancy and childhood children mirror their
caretakers’ responses when interpreting internal
states of pain, arousal, and anxiety
Over time children may come to label a host of
external cues as potentially threatening and certain
internal sensations as fearful; this is the
hypothesized mechanism of GAD, specific phobias
(Kendall and Ronan, 1990), and some types of
PTSD (Main and Hesse, 1990)
Etiologic Example: OCD
Genetic: Likely a vulnerability is genetically
transmitted, based upon increased concordance
rates among monozygotes vs. dizygotes and
increased rates among 1st degree relatives of
Neurophysiology: Increased metabolism in
orbitofrontal and caudate systems (e.g., hyperactive
caudate; PET scans); abnormalities supposed in
circuits linking basal ganglia and frontal lobes
(Baxter et al, 1992)
Neuroendocrine: Individuals with OCD have shown
elevated levels of Oxytocin (behavioral effects of
which typically contribute to cognitive, grooming,
affiliative, and reproductive behaviors in animals)
Insecure Resistant - Hyperactivating
Insecure Avoidant - Inhibited
Disorganized - No adaptive strategy
– Frightening, unpredictable parents
Attachment Research
Insecure attachment may be a risk factor
for the development of childhood anxiety
An attachment study showed that 80% of
children born to insecure mothers were
classified as insecurely attached children
The presence of behavioral inhibition does
not seem to increase the risk of being
insecurely attached and vice versa
The Impact of Trauma Is Developmentally Sensitive
Affect Regulation

Cloitre et al., 1997

The Impact of Trauma Is Developmentally Sensitive
Interpersonal Functioning
Inventory of Interpersonal Problems

Cloitre et al., 1997

The key idea is that phobias develop as a
defense against anxiety which is produced
by repressed id impulses.
Anxiety is displaced from the id impulses
to a fear object that is linked symbolically
(and generally more acceptable).
By avoiding the phobic object, one avoids
dealing with repressed childhood conflicts.
Anxiety is the most prevalent mental health
disorder in children and teens
– Estimated at 6 – 20%
– Difficult numbers because subthreshold anxiety (not
meeting DSM criteria) can also cause severe
Developmental progression of anxiety disorders
in adulthood
– Untreated childhood anxiety typically continues into
– Leads to an increased risk of depressive disorders
 Albano, Chorpita, & Barlow (2003). Childhood Anxiety Disorders. In Mash & Barkley (Eds.). Child Psychopathology: Second Edition. (pp. 279-329). New York: Guildford
 Costello et al, 2004
Epidemiology (2)
Girls are more likely than boys to report an anxiety
disorder, esp. specific phobia, panic, agoraphobia, &
separation anxiety disorder
Children often develop new anxiety disorders over
time (even if the old ones go away)
Anxiety or depressive disorders in adolescence predict
a 2-3x increase risk of anxiety or depression in
adulthood (Pine et al, 1998) and lower academic
achievement (Woodward & Fergusson, 2001)
Anxiety in the 1st grade has been shown to predict
anxiety and low academic achievement in reading and
math in the 5th grade (Ialongo et al, 1995)
Epidemiology (3): Non-Referred
High prevalence of anxiety disorders in non-
referred children:
– 3.5% for Separation Anxiety D/O
– 2.9% for Overanxious D/O
– 2.4% for Simple Phobia
– 1% for Social Phobia (Anderson et al, 1987)
Bowen (1990) reported 3.6% prevalence of
Separation Anxiety D/O and 2.4% prevalence
of Overanxious D/O in 12 – 16 y/o population
Lifetime prevalence of panic d/o was 0.6%
and for GAD 3.7% (Whitaker, 1990)
Epidemiology (4)
A pediatric primary care sample of 7 – 11 y/o
revealed a 1-year prevalence of anxiety d/o of
15.4%; Simple Phobia (9.2%), Separation Anxiety
D/O (4.1%), and Overanxious D/O (4.6%) were
most common (Benjamin 1990)
A 3 – 4 year f/u study of children/adolescents with
anxiety d/o showed a high remission rate with 82%
no longer meeting criteria for their initial anxiety d/o
(Last et al)
– Separation Anxiety D/O had the highest recovery rate
(96%) and panic the lowest (70%); during this f/u period,
30% of children developed new psych d/o and half
developed new anxiety d/o
Risk and Protective Factors
Behaviorally inhibited young children have a
greater likelihood of anxiety disorders in
middle childhood
Offspring of parents with anxiety disorders
have a greater risk of anxiety disorder and
high levels of functional impairment
Insecure attachment relationships with
caregivers (specifically anxious/resistant
attachment) increases the risk of childhood
anxiety disorders
Clinical Course
The usual course of most anxiety disorders is chronic
with waxing and waning over time
Individuals sometime “trade” one anxiety disorder for
another over time
Commonly those with GAD report they’ve felt anxious
their entire life; over half presenting for treatment
report onset in childhood or adolescence; but onset
occurring after 20 is not uncommon; chronic but
fluctuating course
With Panic D/O, typically attacks become less severe
if they occur more often
Some anxieties, such as specific phobias, often
dissipate with age, but those that persist into
adulthood remit only infrequently (20%)
Clinical Course (2)
Social Phobia, on the other hand, most often sets on in
childhood and is commonly lifelong and continuous,
although it may fluctuate in intensity with life stressors and
Most individuals with OCD show improvement with time, but
about 15% show progressive deterioration and 5% have
episodic course; however, an NIMH 2 – 7 year f/u study
found 43% still meeting diagnostic criteria with only 11%
totally asymptomatic
As with other anxiety disorders, the symptoms of PTSD
often vary over time. Complete recovery occurs within 3
months in about half of cases.
Separation Anxiety Disorder may develop after a stressor
(e.g., death of a relative or pet, relocation, etc.) and occur as
early as preschool; adolescent onset is rare; typically it
waxes and wanes; although it may be expressed as Panic
Disorder in adults, most children are free from anxiety
disorders as they adults
DSM Diagnoses (1)

DSM III-R included only 3 childhood anxiety

(1) Separation Anxiety Disorder (which remains);
(2) Overanxious Disorder, which is now
subsumed under GAD; and
(3) Avoidant Disorder, which is now subsumed
under Social Phobia
DSM Diagnoses (2)
DSM-IV disorders include:
(1) Separation Anxiety Disorders
(2) Panic Disorder
(3) Specific Phobia
(4) Social Phobia (Social Anxiety Disorder)
(5) Obsessive-Compulsive Disorder
(6) Posttraumatic Stress Disorder
(7) Acute Stress Disorder
(8) Generalized Anxiety Disorder
– Selective Mutism
– Somatic symptoms
– Trichotillomania
DSM: Separation Anxiety Disorder
Developmentally inappropriate and excessive anxiety
concerning separation from home or from those to
whom the individual is attached, as evidenced by 3 or
Excessive distress upon separation from home or attachment
figures occurs or is anticipated
Excessive worry about losing or harm befalling attachment figures
Excessive worry that an event will lead to separation from an
attachment figure (e.g., kidnapping)
Reluctance to attend school b/c of fear of separation
Reluctance to be alone or without attachment figures at home or
other locations
Reluctance to sleep alone or away from home
Repeated nightmares involving separation
Repeated complaints of physical symptoms when separation occurs
or is anticipated
Duration at least 4 weeks
Separation Anxiety Disorder
Affected children tend to come from closely knit
The kids may exhibit social withdrawal, apathy, and
sadness or difficulty concentrating when separated
Concerns about death and dying are common
These children are often viewed as demanding
Adults with SAD are typically over-concerned about
their children and spouses
Prevalence estimates about 4% in children and
young adolescents
More common in 1st degree relatives than general
Panic Attacks
Quite common among
Panic Attacks
Can occur within the context of other mental disorders (e.g.,
Mood D/Os, Substance-Related D/Os, etc.) and some general
medical conditions (e.g., cardiac, respiratory, vestibular, GI).
3 characteristic types of panic: (1) Unexpected (uncued); (2)
situation bound (cued); and (3) situationally predisposed.
Individuals who seek care will typically describe intense fear,
report that they fear they’re about to die, go crazy, have an
Individuals typically report a desire to flee or leave where they ’re
With unexpected panic attacks, over time the attacks typically
become situationally bound or predisposed, although unexpected
attacks may occur
The occurrence of unexpected panic attacks is required for a dx
of Panic D/O; situationally bound or predisposed attacks are
common in Panic D/O but also occur in the context of other
anxiety disorders (e.g., specific and social phobia, PTSD)
Relationship between PD and other Anxiety Disorders
What does a panic attack look like
in a child?
Children generally report physical symptoms, rather than
psychological symptoms
May suddenly appear frightened or upset without
Often confusing behavior to onlookers
Children may explain their symptoms as responses to
external triggers
Young children may not be able to articulate the intense
fears they experience
Adolescents are generally better at describing what they
experience, especially after the attack has ended
*rarer in children
DSM: Panic Disorder
Both (1) and (2):
– recurrent unexpected Panic Attacks
– at least one of the attacks has been followed by 1 month (or more) of one (or
more) of the following:
persistent concern about having additional attacks
worry about the implications of the attack or its consequences (e.g., losing control,
having a heart attack, “going crazy”)
a significant change in behavior related to the attacks
Absence of Agoraphobia
The Panic Attacks are not due to the direct effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g.,
The Panic Attacks are not better accounted for by another mental
disorder, such as Social Phobia (e.g., occurring on exposure to feared
social situations), Specific Phobia (e.g., on exposure to a specific phobic
situation), OCD (e.g., on exposure to dirt in someone with an obsession
about contamination), PTSD (e.g., in response to stimuli associated with
a severe stressor), or Separation Anxiety D/O (e.g., in response to being
away from home or close relatives).
Panic Disorder
Patients often are hypersensitive about physical cues and medication side effects
Reported rates of comorbid MDD are high, ranging from 10-65%; in 2/3 of these individuals
depression co-occurs with panic d/o or follows panic; in the remaining 1/3, the depression
precedes the panic
Comorbidity with other anxiety disorders is common – social phobia and GAD (15-30%),
specific phobia (2-20%), and OCD (up to 10%). PTSD and Separation Anxiety are also
strongly comorbid, along with hypochondriasis.
No consistent abnormalities in lab results, but compensated respiratory alkalosis (decreased
bicarb/CO2 with almost normal pH) sometimes noted.
Lactate and elevated CO2 can be used to induce panic in sufferers
Correlation with numerous general medical symptoms, including dizziness, arrhythmias,
hyperthyroidism, asthma, COPD, IBS; however, the nature of the association is unclear.
Debate about whether or not MVP and thyroid disease is more common among sufferers
Lifetime prevalence in community samples generally 1-2% (but reported as high as 3.5%);
one-year prevalence rates 0.5-1.5%; higher rates in clinic samples (10% in individuals referred
for mental health consultation); 10-30% in general medical clinics and up to 60% in cardiology
1/3 to ½ of community samples has comorbid agoraphobia, but the co-occurrence is much
higher in clinical samples
Age at onset varies, but typically late adolescence/mid-30s; occasionally onset in childhood;
after 45 y/o rare.
Agoraphobia typically develops within the first year, but can occur at any time
1st degree biological relatives are up to 8x more likely to develop Panic D/O; if age of onset is
<20 y/o, 1st degree relatives are up to 20x more likely to develop same.
DSM: Specific Phobia
Marked and persistent fear that is excessive or unreasonable, cued
by the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response, which may take the form of a
situationally bound or situationally predisposed Panic Attack. In
children, the anxiety may be expressed by crying, tantrums, freezing,
or clinging.
The person recognizes that the fear is excessive or unreasonable.
In children, this feature may be absent.
The phobic situation(s) is avoided or else is endured with intense
anxiety or distress.
Types: Animal Type
Natural Environment Type (e.g., heights, storms, water)
Blood-Injection-Injury Type
Situational Type (e.g., airplanes, elevators, enclosed places)
Other Type (e.g., fear of choking, vomiting, or contracting an illness;
in children, fear of loud sounds or costumed characters)
Specific Phobia
Rates of co-occurrence with other disorders is 50-80%
Usually the comorbid condition causes more distress than the specific
phobia; i.e., only 12-30% of affected individuals are estimated to seek help
strictly for a specific phobia
Vasovagal fainting response is characteristic of Blood-Injection-Injury Type
specific phobias (about 75% of patients report fainting in such situations)
Women:men = 2:1
Although phobias are common in the general population, they rarely result
in sufficient impairment
Community samples show point prevalence rates of 4-8.8% and lifetime
prevalence rates of 7.2-11.3%; there is decline in the elderly
First symptoms usually occur in childhood or early adolescence
Predisposing factors include traumatic events, unexpected Panic Attacks in
the now feared situation, observation of others undergoing trauma or
demonstrating fearfulness, and informational transmission (e.g., repeated
parental warnings, media coverage).
Feared objects are those which may actually represent some threat or
have represented a threat during some point in human evolution
Familial aggregation
DSM: Social Phobia
A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that s/he will act in a way
(or show anxiety symptoms) that will be humiliating or embarrassing. In
children, there must be evidence of the capacity for age-appropriate social
relationships with familiar people and the anxiety must occur in peer
settings, not just in interactions with adults.
Exposure to the feared social situation almost invariably provokes anxiety,
which may take the form of a situationally bound or situationally
predisposed Panic Attack. In children, the anxiety may be expressed by
crying, tantrums, freezing, or shrinking from social situations with
unfamiliar people.
The person recognizes that the fear is excessive or unreasonable. In
children, this feature may be absent.
The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.
The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person ’s normal
routine, occupational (academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia.
In individuals under 18 years, the duration is at least 6 months
Social Phobia
In feared social or performance situations, individuals
with SP experience concerns about embarrassment
and are afraid that others will judge them to be
anxious, weak, “crazy” or stupid.
Almost always experience physical signs of anxiety
(e.g., palpitations, tremors, sweating, GI, blushing,
Typically there is avoidance of social situations
Common associated features include hypersensitivity
to criticism or rejection; difficulty being assertive, low
self-esteem and feelings of inferiority.
Lifetime prevalence 3-13%
Occurs more frequently among 1st degree relatives
Obsessive Compulsive Disorder

Insanity is doing the same thing over and

over again and expecting different results.
-Albert Einstein
DSM: Obsessive-Compulsive Disorder
Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
*recurrent and persistent thoughts, impulses, or images that are experienced, at
some time during the disturbance, as intrusive and inappropriate and that cause
marked anxiety or distress
*the thoughts, impulses, or images are not simply excessive worries about real-
life problems
*the person attempts to ignore or suppress such thoughts, impulses, or images,
or to neutralize them with some other thought or action
*the person recognizes that the obsessional thoughts, impulses, or images are a
product of his/her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
*repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts
(e.g., praying, counting, repeating words silently) that the person feels driven to
perform in response to an obsession, or according to rules that must be applied
*the behaviors or mental acts are aimed at preventing or reducing distress or
preventing some dreaded event or situation; however, these behaviors or mental
acts either are not connected in a realistic way with what they are designed to
neutralize or prevent or are clearly excessive
Affected individual has recognized that the obsessions or compulsions are
excessive or unreasonable. This does not apply to children.
Time consuming (more than 1 hour/day)
Most common obsessions include contamination, repeated doubts, ordering,
aggressive or horrific impulses, and sexual imagery
Individuals tend to try and neutralize their obsessive anxiety with behaviors
that ultimately become compulsive
When individuals try to resist the compulsions, they have a sense of
mounting anxiety that is partially relieved (but perpetuated) by yielding to the
Hypochondriacal concerns are common, with repeated visits to physicians
to seek reassurance
High concordance with MDD, Eating D/O, and GAD and other anxiety d/o in
In children, it may be associated with other anxiety d/o, Learning D/O,
Disruptive Behavior D/Os
Comorbid obsessive-compulsive spectrum disorders (trichotillomania, body
dysmorphic d/o, and habit d/o such as nail biting) are uncommon but not
There is an established high incidence of OCD in children and adults with
Tourettes (range estimates 35-50%); in reverse, the numbers are smaller
OCD (2)
Between 20-30% of individuals with OCD report current or past
Children often do not seek help, and the symptoms may not be
as ego-dystonic as in adults
In adults the disorder is equally common in males and females;
in childhood onset, the disorder is more common in boys than
Community studies of children/adolescents estimates lifetime
prevalence at 1-2.3% and one-year prevalence of 0.7%
Usual onset is late adolescence/early adulthood but may begin in
childhood; males typically have an earlier onset than females
(males, 6-15; females 20-29)
Higher concordance for mono than dizygotic twins
Higher risk of OCD amongst 1st degree relatives of patients with
OCD and/or Tourettes
Pregnancy and childbirth are a strong risk factor for new-onset
DSM: Post-Traumatic Stress Disorder
1) Exposed to a traumatic event in which:
– The person experienced, witnessed, or was confronted with an event
or events that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
– The person’s response involved intense fear, helplessness, or horror.
In children, this may be expressed instead by disorganized or agitated
2) The traumatic event is persistently reexperienced in one (or more) of
the following ways:
– Recurrent and intrusive distressing recollections of the event, including
images, thoughts, or perceptions. In young children, repetitive play
may occur in which themes or aspects of the trauma are expressed.
– Recurrent distressing dreams. In children, there may be frightening
dreams without recognizable content
– Acting or feeling as if the traumatic event were recurring (includes a
sense of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes). In young children, trauma-specific
reenactment may occur
– Intense psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
DSM: Post-Traumatic Stress D/O (2)
3) Physiological reactivity on exposure to internal or external cues
4) Persistent avoidance of stimuli associated with the trauma and numbing of
general responsiveness (not present before the trauma), as indicated by
three (or more) of the following:
– efforts to avoid thoughts, feelings, or conversations associated with the
– efforts to avoid activities, places, or people that arouse recollections of the
– inability to recall an important aspect of the trauma
– markedly diminished interest or participation in significant activities
– feeling of detachment or estrangement from others
– restricted range of affect (e.g., unable to have loving feelings)
– sense of a foreshortened future (e.g., does not expect to have a career,
marriage, children, a normal life span)
Persistent symptoms or increased arousal (not present before the trauma), as
indicated by two (or more) of the following:
– difficulty falling or staying asleep
– irritability or outbursts of anger
– difficulty concentrating
– hypervigilance
– exaggerated startle response
Duration of the disturbance is more than 1 month.
Types of Trauma
Child Maltreatment
Community violence (witness, victim)
Natural disasters (fires, hurricanes)
Motor vehicle collisions
Disasters (fires, earthquakes)
War and terrorism
Prevalence of Trauma

 Lifetime Prevalence: 1-14%

 Child sexual abuse: studies of 30-40%
 Child physical abuse: 10%
 Witnesses of domestic violence 54%
 Single-incident disaster: 10%
 Motor vehicle collisions:
– Most common form of unintentional injury in children

 Prevalence following war / terrorism

 War
 PTSD diagnosis-Current 18%-37%
 PTSD diagnosis-Lifetime 21%
 Severe PTSD symptoms 31%

 Oklahoma City 36%

(In the brain)

Normal Brain: Look at the Hippocampus!

(In the brain)

•Recent research points to

the role of the
hippocampus in PTSD.
•One job of the
hippocampus is to
constantly be generating
new cells to form new
•Patients with PTSD have a
reduction in volume of the
hippocampus because it
(In the brain)

War veterans have shown an 8%

reduction in the right hippocampus (no
differences in other parts of the brain).

Damage to the hippocampus following

exposure to the stress brought on by
childhood abuse leads to distortion and
fragmentation of memories.
 Traumatic events experienced prior to age 11
are 3x more likely to result in PTSD
 Psychological impact of traumatic events tends
to persist or worsen over time in children
 Parents tend to underestimate both the intensity
and duration of their children’s stress reactions
 Many trauma victims never develop PTSD
 What predicts who develops PTSD?
 Closer physical proximity
 Closer emotional proximity (death)
 More exposure to media coverage
 Cognitive factors
 Locus of control
 Trauma-specific attributions
PTSD (1)
Individuals may describe painful guilt feelings about
surviving when others don’t survive, or about the things
they had to do in order to survive
Recent immigrants from areas of civil unrest may have an
increased prevalence
Lifetime prevalence approx 8% of adults in US (1 – 14%)
Symptoms usually begin within the first 3 months of the
trauma experience
Frequently a person’s reaction to trauma meets criteria for
an Acute Stress D/O in the immediate aftermath
Severity, duration, and proximity of an individual ’s
exposure to the trauma are the most important factors
affecting the likelihood of developing this disorder
Some evidence of a heritable component
A h/o of depression in a 1st degree relative is related to an
increased vulnerability
PTSD (2)
Partial symptomatology is common
The “fight or flight” response is less adaptive in
young children than adults
Comorbid conditions are common
Girls are generally more symptomatic than
Younger children seem to demonstrate more
avoidance symptoms, whereas older children
suffer more reexperiencing and arousal
DSM: Acute Stress Disorder
The person has been exposed to a traumatic event in which both of the following were
The person experienced, witnessed, or was confronted with an event or events
that involved actual or threatened death or serious injury, or a threat to the
physical integrity of self or others
The person’s response involved intense fear, helplessness, or horror
Either while experiencing or after experiencing the distressing event, the individual has three
(or more) of the following dissociative symptoms:
A subjective sense of numbing, detachment, or absence of emotional
A reduction in awareness of his/her surroundings (e.g., “being in a daze”)
Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
– The traumatic event is persistently reexperienced in at least one of the following ways:
recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving
the experience; or distress on exposure to reminders of the traumatic event.
– Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places, people)
– Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability,
poor concentration, hypervigilance, exaggerated startle response, motor restlessness)
– The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs
within 4 weeks of the traumatic event
Acute Stress Disorder
As a response to a traumatic event, the individual
develops dissociative symptoms
Individuals may have a decrease in emotional
responsivity; feeling guilty, anhaedonic
Individuals are at increased risk of developing PTSD
Rates ranging from 14-33% have been reported for
individuals exposed to severe trauma
Symptoms are experienced during or immediately
after the trauma, lasting at least 2 days, and
resolving within 4 weeks; if symptoms persist
beyond 1 month, PTSD may be diagnosed if criteria
are met
DSM: Generalized Anxiety Disorder
– Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for at least 6 months, about
a number of events or activities (such as work or school
– The person finds it difficult to control the worry.
– The anxiety and worry are associated with three (or more)
of the following six symptoms (with at least some
symptoms present for more days than not for the past 6
months). Only one item is required in children.
restlessness or feeling keyed up or on edge
being easily fatigued
difficulty concentrating or mind going blank
muscle tension
sleep disturbance (difficulty falling or staying asleep,
or restless unsatisfying sleep)
Many people with GAD experience somatic sx (e.g., sweating,
nausea, diarrhea) and an exaggerated startle response
Autonomic hyperarousal is less common in GAD than in other
anxiety d/o
Frequently comorbid with Mood D/Os, other Anxiety D/Os, and
Substance-Related D/Os
In children/adolescents worries often focus on school, sporting
events, punctuality, catastrophic events (e.g., earthquakes);
children may also be overly conforming, perfectionistic, and
overzealous in seeking approval
Diagnosed somewhat more in women than men (55-60%)
One-year prevalence 3%; lifetime prevalence 5%
Anxiety as a trait has a familial association
DSM: Selective Mutism
Consistent failure to speak in specific
social situations (in which there is an
expectation for speaking, e.g., at school)
despite speaking in other situations
Duration of at least one month with
significant disturbance
Selective Mutism
Associated features often include shyness, fear
of social embarrassment, social isolation, and
withdrawal, clinging, negativism, temper
tantrums, and oppositional behavior (esp at
Teasing by peers is common
Although affected children usually have normal
communication skills, SM is occasionally
associated with a communication disorder
<1% of kids seen in mental health settings
Onset is usually before age 5
DSM: Trichotillomania
Recurrent pulling out of hair resulting in
noticeable hair loss
An increasing sense of tension
immediately before pulling out the hair or
when attempting to resist the behavior
Pleasure, gratification, or relief when
pulling out the hair
Sites of hair pulling may include any region of the body (most
common is the head, eyebrows, and eyelashes, but also
axillary, public, perirectal occur)
May occur in episodes scattered throughout the day or in less
frequent but sustained periods lasting for hours
Often occurs during periods of relaxation and distraction (e.g.,
watching TV or reading) but may occur during stress as well
Examining the hair root, twirling it off, pulling the strand
between the teeth, or trichophagia (eating hairs) may occur and
can result in bezoars
Histological examination of affected areas shows damage to
hair follicles and short, broken hairs
No gender differences among children; women>men
Occurrence is unknown; 0.6% lifetime rate among a study of
college students
Affected individuals often deny the hair pulling
People may pull hair from pets, dolls, or clothes
Assessment of Anxiety in Children

There is often low concordance between

child and parent reports of anxiety
Mothers tend to over-report anxiety
Rating Scales

Screen for Child Anxiety Related

Emotional Disorders (SCARED)
Multidimensional Anxiety Scale for
Children (MASC)
Leyton Inventory
Achenbach (Child Behavior Checklist)
Treatment of Anxiety Disorders in
Children (Psychotherapy)
An insecure bond between parent and child
may be an important contributing etiologic
factor; thus treatment aimed at improving
these interactions is crucial
– Indications: OCD and phobias (with ERP),
Panic, GAD, SAD
Two studies support the use of
psychodynamic psychotherapy (Heinicke)
Treatment of Anxiety Disorders in
Children (Medication)
Four DBPC studies of TCAs for school refusal
show conflicting results
Case reports support the use of TCAs for
children/adolescents with Panic D/O
Alprazolam may be useful in children with
overanxious or avoidant disorders
Benzodiazepines may be useful for adolescents
with Panic D/O
Alpha-2 agonists and beta-blockers may be
effective for PTSD
Treatment of Anxiety Disorders in
Children (Medication)
SSRIs have been show to be efficacious in
numerous studies
Two RDBPC studies of Effexor XR show somewhat
conflicting but generally positive results (Rynn and
Riddle et al)
Zoloft has the best safety data in children and
adolescents (studies extend two years)
FDA approval only for OCD:
– Fluoxetine (Prozac®) 7 – 17 y/o
– Sertraline (Zoloft®) 6 – 17 y/o
– Fluvoxamine (Luvox®) 8 – 17 y/o
– Clomipramine (Anafranil®) 11 – 17 y/o
Child and Adolescent Anxiety Multimodal Study (CAMS),
2008 (Walkup et al, 2008).
Compared CBT, medications, and combined for treatment of
anxiety disorders
Randomly assigned 488 children and adolescents with
Separation Anxiety Disorder, Social Phobia, or Generalized
Anxiety Disorder, aged 7 to 17 years, to one of four
treatment groups for 12 weeks.
– CBT for 14 sessions
– Sertraline up to 200 mg/day
– CBT + Sertraline
– Placebo
Over 80% of children who received combined treatment
improved, as opposed to 60% receiving CBT only and 55%
receiving medication only; although there was no statistical
separation between the CBT and medication groups
All treatments were statistically more effective than placebo,
which led to improvement in only 24% of subjects.
OCD Treatment
No specific predictors of treatment outcome have been
identified for children; in adults comorbid schizotypy and tic
disorders have been identified as impediments
CBT with Exposure and Response Prevention (ERP)
Children who acknowledge that their obsessions are
senseless and their rituals are distressing may be better
candidates for CBT, although lack of insight doesn ’t
necessarily render CBT ineffective
SSRIs and clomipramine (best studied in children); typically
functioning best at higher doses
A substantial minority will not respond until 8 or 12 weeks of
In those partially responsive to an SSRI, augmentation may
be useful (only haldol and klonipin have proven benefit in
OCD Medication Studies
Clomipramine -DeVeaugh-Geiss et al.,
Fluoxetine - Riddle et al., 1992
Sertraline - March et al., 1998
Fluvoxamine - Riddle et al., 2001
Fluoxetine - Geller et al., 2001
Paroxetine - Geller et al., 2004
Sertraline in Pediatric OCD
March et al, 1998
DBRPC 12 week multisite trial
N = 187; age = 6-17 years; sertraline 200
Sertraline > placebo
Mild side effects
Similar profile of response as
Fluvoxamine in Pediatric OCD
Riddle et al, 2001
DBRPC multisite trial
N = 120; age = 8-17 years; fluvoxamine
50-200 mg/d
Fluvoxamine > placebo
Mild side effects
Fluoxetine in Pediatric OCD
Geller et al., 2001
N=103, ages 7-17 years
13 week RDBPC trial
Dose 10-60 mg/day
Decrease CY-BOCS favored fluoxetine
Paroxetine for Pediatric OCD
Geller et al, 2004
DBPCR 10 week trial
Ages 7-17
Paroxetine > placebo
Mild side effects
OCD Augmentation Strategies
IV Clomipramine
Add second SSRI
Pediatric OCD Treatment Study
N = 112
Ages 7-17 years
3 sites, 12 weeks
Randomly assigned to CBT, Sertraline,
COMB and placebo
PTSD Treatment
Debriefing is a popular intervention after disaster;
unfortunately, there is little evidence documenting
its effectiveness
Treatment involves transforming the child’s self-
concept from victim to survivor
Projective interventions should include steps
depicting recovery to increase the sense of mastery
The literature suggests that desensitization,
relaxation, and other behavioral techniques are
beneficial in treating children with PTSD, but
research is lacking
Revenge fantasies complicate emotional resolution
Sertraline Treatment of Children and Adolescents With Posttraumatic
Stress Disorder, RDBPC (Robb et al, 2011)
131 children and adolescents (6–17 years old) meeting DSM-IV criteria
for PTSD received 10 weeks of double-blind treatment with sertraline
(50–200mg/day) or placebo; primary efficacy measure UCLA PTSD-I
Randomized to sertraline (n=67; female, 59.7%; mean age, 10.8) or
placebo (n=62; female, 61.3%; mean age, 11.2)
There was no difference between sertraline and placebo in least squares
(LS) mean change in the UCLA PTSD-I score, either on a completer
analysis (−20.4±2.1 vs. −22.8±2.1; p=0.373) or on an last observation
carried forward (LOCF) end point analysis (−17.7±1.9 vs. −20.8±2.1;
Attrition was higher on sertraline (29.9%) compared to placebo (17.7%).
D/c due to adverse events was 7.5% with sertraline & 3.2% with placebo
Sertraline was a generally safe treatment in children and adolescents
with PTSD, but did not demonstrate efficacy when compared to placebo
during 10 weeks of treatment
PTSD Treatment (2)
Small open trials have suggested propranolol
and clonidine for persistent arousal
Zoloft and Paxil FDA approved for adults; small
open trials have suggested the same for SSRIs
in children; gabapentin and antipsychotics
sometimes reportedly useful in adults
EMDR (Eye Movement Desensitization
Retraining) eye movement therapy shown
effective in adults and one child trial (Chemtob
et al, 2000, adults; Ahmad & Sundelin-Wahlsten,
2008, children)
NAC is a metabolite of cysteine, an amino acid; its metabolite,
cystine, reduces synaptic release of glutamate and enhances
glial clearance of glutamate, protecting against glutamate
The restoration of the extracellular glutamate concentration in
the nucleus accumbens seems to block compulsive behaviors
Single case report of a patient with SSRI refractory OCD, who
received augmentation of Prozac with NAC led to marked
decrease in Y-BOCS (Lafleur et al, 2006)
Randomized DBPC study of 45 women and 5 men with
trichotillomania (ages 18 – 65) were assigned to 12 weeks of
NAC up to 2400 mg/d vs. placebo; after 9 weeks of treatment,
54% of those taking NAC responded to treatment favorably
(Grant et al, 2009)