IACAPAP Textbook of Child and Adolescent Mental Health

ANXIETY DISORDERS

Chapter

F.1

ANXIETY DISORDERS IN
CHILDREN AND ADOLESCENTS
NATURE, DEVELOPMENT, TREATMENT
AND PREVENTION
2018 edition
Ronald M Rapee

Ronald M Rapee PhD
Professor, Centre for
Emotional Health, Departmentof Psychology, Macquarie
University, Sydney, Australia
Conflict of interest: receiving
royalties from the book,Helping your Anxious Child:
A Step by Step Guide for
Parents. Proceeds from salesof the Cool Kids program go to

the Centre for Emotional Healthat Macquarie University toassist research and treatment
for anxious children – noindividual receives any income
from these materials.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2018. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Rapee RM. Anxiety disorders in children and adolescents: Nature, development, treatment and prevention. In
Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2018.

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IACAPAP Textbook of Child and Adolescent Mental HealthIt was not very many years ago that anxiety disorders in children were thought
to be relatively rare and low impact conditions. As a result, our empiricalknowledge about child anxiety is less extensive than it is for the adult conditions.
Nevertheless, the past 15 to 20 years have seen a dramatic increase in the numberof studies examining child anxiety and we are now building a good understandingof the nature, development and treatment of these disorders. Even more recently,interest has started to focus on possible prevention of anxiety. Given the overlap
between anxiety and depression as well as the continuity from childhood into
adulthood, this work has far-reaching implications for prevention of internalisingdifficulties across the lifespan.
Compared with research in the adult realm that tends to split disorders
very specifically, within the child and adolescent fields, there is a more common
tendency to examine anxiety relatively broadly and, in many cases, to examineinternalising disorders as a whole. Therefore, in the current chapter, I will write
about anxiety disorders very broadly and consider factors relevant to all the anxiety
disorders as a group. This is especially the case for therapy, where most empiricallysupported psychological treatment packages have tended to include children acrossthe range of anxiety disorders. Given that other chapters in this book focus on
obsessive compulsive disorder, post-traumatic reactions and separation anxiety, I
will focus, where possible, more directly on the remaining disorders – generalised
anxiety, social anxiety and specific phobias. In fact, since publication of the DSM5, obsessive compulsive disorder and post-traumatic stress disorder are no longer
included with the anxiety disorders, even though they share many characteristics,
risk factors, and treatments. To reduce repetition, I will generally use the terms childanxiety or childhood anxiety to refer to anxiety in both children and adolescents,
unless specific age distinctions are necessary.

DESCRIPTION AND DIAGNOSISThe core feature of anxiety disorders is avoidance. In most cases thisincludes overt avoidance of specific situations, places, or stimuli, but it may also
involve more subtle forms of avoidance such as hesitancy, uncertainty, withdrawal,
or ritualised actions. These behaviours are relatively consistent across disorders andthe key difference between specific disorders is the trigger for this avoidance. The
avoidance is generally accompanied by affective components of fearfulness, distressor shyness. Some children, however, especially younger ones, may have difficulty
verbalising these emotions. Anxiousness occurs due to an expectation that somedangerous or negative event is about to occur – in other words, an expectation of
threat. Therefore, in identifying the anxious child, it is crucial to determine thatthe avoidance occurs due to an expectation of some form of threat. For example,
two children may say that they do not want to go to school. In one case thisappears to be due to the fact that they are having more fun going to the shopswith their friends; in the second case it appears to be due to a belief that otherchildren are making fun of the child. Even though both may superficially seem to
be avoiding school, the former case would not reflect anxiety since the behaviour
is not motivated by a perceived threat. All of the anxiety disorders will involvean anticipation of threat, which may take the form of worry, rumination, anxious
anticipation, or negative thoughts. The key differences between disorders lie in thecontent of these beliefs, as will be described below. In addition to the described
beliefs, behaviours, and emotions, anxious children will often report a range ofassociated physical complaints reflecting heightened arousal; however, these are rarely
specific to a given disorder and hence are rarely diagnostic. Physical symptoms thatare common among anxious children include headaches, stomach aches, nausea,
vomiting, diarrhoea, and muscle tension. In addition, it is common for many
anxious children, especially those that worry considerably, to have difficulty withsleep.

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Internalisingdisorders
As opposed to“externalising” or“undercontrolled” disorders”– such as conduct disorder,in which children tend
to externalize or act out
inner conflict or emotions,e.g., through aggression– internalizing disorders
reflect problems within
the self, such as fears,
worrying and unhappiness,traditionally subsumed
under the rubric of“neuroses”, "overcontrolled"
or “overinhibited" problems.
Children with internalisingdisorders tend to deal withproblems and emotional
conflict internally rather
than acting them out.
Internalizing disorders
usually cause more distressto the child than to thosearound them, the oppositeof what happens withexternalizing disorders.

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Table F.1.1 Core and associated features of the various anxiety disorders.
DISORDER

Separation
anxietydisorderCORE FEATURES
Fear or concern thatsomething bad will happen
to the child or attachment
figure (commonly a parent)
when they are separated.
As a result of this belief, thechild avoids separation fromthe attachment figure.

ASSOCIATED FEATURES
•
•
•
•
•

Generalised
anxietydisorderA tendency to worry abouta wide range of negative
possibilities, that something
bad will happen

•
•
•
•

Social phobia

Fear and avoidance ofsocial interactions or social
performance due to a belief
that others will negatively
evaluate the child•••SpecificphobiasThe core feature of specificphobias involves fear andavoidance in response toa range of specific cues,
situations, or objects. Thereis a common belief that theobject or situation will leadto personal harmDreams or nightmares about separation
Refusal to face situations that involve separation, including
sleeping away from home, going to school, visiting friends orrelatives, staying at home alone or with child minders
Worry about the consequences of separation including fears of
being kidnapped or injured or of the attachment figure being hurt,or killed while apart
Physical symptoms when separation is anticipated including,vomiting, diarrhoea, and stomach aches
Repeated and extensive worry about several areas such as family
finances, friendships, schoolwork, sports performance, self andfamily health, and minor, daily issues.
Tendency to repeatedly seek reassurance from parents or others
about fears.
Avoidance of novelty, negative news, uncertain situations, andmaking mistakes.
Physical symptoms, sleeplessness and irritability when worried.
Avoidance of a range of social activities or situations including,speaking or performing in front of others, meeting new children,
talking to authority figures such as teachers, being the centre ofattention in any way, and for teenagers, fears of dating
Worries about negative evaluation from others including that
others will think they are unattractive, stupid, unpleasant, overly
confident, or odd
A limited number of friends and difficulty making new friends
High levels of self-consciousness or self-focussed attention

Some common fears in children include:• Animals such as dogs or birds• Insects or spiders• The dark
• Loud noises and especially storms• Clowns, masks, or unusual looking people• Blood, illness, injections

Panic Disorder and agoraphobia*
Panic
DisorderAgoraphobia

Experience and fear of
unexpected panic attacks,
commonly involving several
somatic symptoms andfears of dying or going
crazy.

•

Agoraphobia involves
an additional fear andavoidance of several"agoraphobic" situations,commonly due to a fear ofexperiencing a panic attackin those situations.

•

•
•

•
•

Several somatic symptoms that usually peak relatively quickly andlast for a specific period
Symptoms commonly include palpitations, breathlessness,dizziness, trembling, and chest pain
At least some attacks occur unexpectedly or "out of the blue"
Avoidance of situations due to fear of symptoms or theirconsequences
Common agoraphobic situations include places from which quick
escape is difficult such as public transport, enclosed spaces,
cinemas, hairdressers, or heavy traffic.
There is a common reliance on specific safety cues, commonly asafe attachment figure.

* Both panic disorder and agoraphobia have their mean age of onset in early adulthood and hence are rare in childhood. Only
occasional cases occur prior to 15 years and small numbers will begin to present from 15 to 18 years.

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As mentioned, the key differences between specific anxiety disorders
involve the particular triggers for the anxiousness, the situations that are avoided,
and the content of the beliefs, as shown in Table F.1.1. Separation anxiety is
described in detail in Chapter F.2.

Anxiety-related disorders
As mentioned, two disorders that were previously incorporated among
the anxiety disorders are no longer included under this rubric in the latest
version of the DSM. They are covered in their own chapters and hence will be
addressed only briefly here. Children with obsessive compulsive disorder (OCD)
report repetitive and intrusive thoughts, images or urges, often accompanied byrepeated characteristic actions or behaviours with the goal of reducing anxiety. The
mental components commonly focus on some expected threat or danger (hence
the overlap with anxiety disorders), although sufferers from some forms of OCD
may fail to report threat expectations and may focus more on a sense of disgust
and a belief that certain actions simply “feel right”. When a threat expectation
does exist, the corresponding rituals are generally aimed at preventing or undoing
the expected danger. In children, the picture is complicated by the fact that many
children, especially younger ones, are unable to clearly describe their beliefs andmotivations. Among children, the most common rituals involve washing (and fears
of contamination) and checking or ordering (and fears of catastrophe) if certain
actions are not adequately performed.
Post-traumatic stress disorder involves a constellation of symptoms ofheightened arousal (e.g., jumpiness), intrusions (e.g., distress on reminders of thetrauma), detachment (e.g., trouble remembering aspects of the trauma, numbness
and flatness), and avoidance that occur following a severe (life threatening) event.
Although, sadly, many children in our world experience life threatening events,
post-traumatic stress disorder is relatively infrequent in childhood (Rapee et al,2009). Some authors have argued that this is because the criteria are not sensitive
to the presentation among children, while others suggest that it may reflect
the reduced sense of past and future in children’s cognitive development. Posttraumatic stress disorder is discussed in detail in Chapter F.4.

Social anxiety
It should be noted thatsocially anxious children
are not necessarily poorin social skills. They arecommonly ignored orneglected rather thanrejected. However, as aresult of their anxiety, they
may sometimes act in asocially awkward mannerand may perform poorly
in social situations. For
example, they may not
speak very much or may
talk very quietly, they may
show poor eye contact,or talk in a hesitant anduncertain manner.

School refusal
Although school refusal is not a formal diagnosis in either the DSM or
ICD, a brief mention is warranted here due to its common discussion in various
circles. There is little doubt that many children do not wish to attend school andin a small percentage of cases they may not attend for lengthy periods. This isoften referred to as school refusal. School refusal is not an anxiety disorder andmay be motivated by many factors aside from anxiety, but when it occurs, anxiety
is a common underlying element. However, anxiety alone is not a sufficient
explanation. School refusal involves both a motivation from the child to notattend school (sometimes due to anxiety) combined with a social and, usually,parental acquiescence to this demand. Naturally, this latter component will vary
between societies depending on the laws for school attendance, social norms, andparental needs (such as extreme poverty). However, where laws and norms provide
an expectation for school attendance (these days in most countries), school refusal
commonly involves some difficulty within the family or at least one parent. For
example, in some cases school nonattendance is partly encouraged by a parent
who may wish the child to help with their own needs (e.g., a physical or mental
disability) or the parent/child relationship may become pathological due to severe
marital difficulties, and so on. In other words, chronic school refusal may reflecta variety of anxiety (or other) difficulties within the child (e.g., fear of the school
work, separation anxiety, social fears, bullying, etc) combined with parental orfamily difficulties and in some cases with social support for nonattendance (seeChapter F.2 for further discussion).

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Comorbidity
As mentioned earlier, it is common for discussions of childhood anxiety
to focus broadly across anxiety (and sometimes related disorders) rather thanfocussing on only a single disorder. One of the main reasons for this is the strong
overlap between the various anxiety disorders and between anxiety and otherinternalising disorders, especially depression. Clinically anxious children rarely
meet criteria for only one disorder. Within treatment-seeking populations, around
80% to 90% meet criteria for more than one mental disorder. The majority, up to75%, meet criteria for more than one anxiety disorder. A further 10% to 30% also
meet criteria for an additional mood disorder. Age differences are apparent here
– around 30% of treatment-seeking adolescents meet criteria for an additional
mood disorder while only around 10% to15% of younger anxious children do so.
About 25% of younger treatment-seeking anxious children will also meet criteria
for an additional behavioural disorder. Similar figures are found in populationbased samples, although the proportion of children with a single anxiety disorderis slightly higher. Nevertheless, even in population-based samples, children with
anxiety disorders are highly likely to have additional anxiety, mood, and behaviouraldisorders. Interestingly, anxious children do not appear to be at greater risk for
substance abuse, most likely reflecting the fact that these children generally obey
rules and do not take risks. However, an overlap between anxiety disorders andalcohol abuse begins to appear from late adolescence or early adulthood (Costello
et al, 2003).

EPIDEMIOLOGY
PrevalencePrevalence estimates of child anxiety have been somewhat variable
across countries and studies due to many factors including variations in criteria,
assessment instruments and sampling. Overall, around 5% of children andadolescents meet criteria for an anxiety disorder during a given period of time inWestern populations (Rapee et al, 2009). There is little data available from othercultures, but one study from Puerto Rico has shown similar rates (Canino et al,2004). In most studies prevalence is highest for specific phobias and moderate forseparation anxiety, generalised anxiety and social phobia.

Gender distribution
Anxiety disorders are more common in females than males in the general
population. Most population studies estimate around 1.5-2 times as many females
compared to males for most anxiety disorders. There is some evidence that thisgender difference appears very early – as young as 5 years of age. In contrast,
distributions within treatment-seeking samples in Western societies are more equaland even include slightly more males, possibly reflecting a social pressure for males
not to experience anxiety.

Age of onset
Anxiety disorders are among some of the earliest disorders to appear
and most commonly begin by middle childhood to mid adolescence. As will be
discussed later, it is common for anxiety disorders to occur within a context oftemperamental inhibition (see below) and fearfulness. Hence it is often difficult
to determine exactly when the actual anxiety disorder first begins and, to someextent, anxious children can often be said to be anxious from birth. Estimates also
differ depending on whether they are determined from pre-adult populations orfrom retrospective reports from adults. Estimates of average age of onset (these are

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IACAPAP Textbook of Child and Adolescent Mental Healthaverages, disorder can start earlier in individual cases) for the different disorders are
as follows:•

Animal phobias – early childhood (around 6-7 years)•

Separation anxiety disorder – early to mid-childhood (around 7-8
years)•

Social anxiety disorder – early adolescence (around 11-13 years)•

Generalised anxiety disorder – widely varying estimates from midadolescence to adulthood•

Panic disorder – early adulthood (around 20-24 years).

CourseAnxiety disorders are among the most stable forms of psychopathology
and show relatively little spontaneous remission. Anxious children are also
at increased risk of developing other disorders during adolescence and into
adulthood. Longitudinal research has shown that anxious children are at greaterrisk for anxiety, mood and externalising disorders in adolescence and for anxiety,mood, and substance use disorders as well as suicide in adulthood (Beesdo-Baum& Knappe, 2012; Bittner et al, 2007).

Other demographic features
Interestingly, anxiety in childhood is characterised by very few
demographic risk factors. There is some evidence that low socioeconomic status
might provide some risk for anxiety but the data are mixed and the degree ofrisk is small. Similarly, some research has hinted that socially anxious children inparticular are more likely to be first born but other research has failed to support
this finding. Most other demographic characteristics fail to predict anxiety (aside
from gender, described earlier). Hence anxious children are not characterised bya given family size, parental marital status, educational attainment or intelligence(Rapee et al, 2009).

ASSESSMENT
Clinical evaluation generally includes a combination of questionnaires,
diagnostic interview and behavioural observation. However, in most clinicalsettings, a diagnostic interview and a small number of questionnaires will be mostappropriate.
Diagnostic interview
Several structured diagnostic interviews exist to assist in determining
either DSM or ICD criteria for childhood disorders including anxiety. Most
interviews include a large number of questions aimed to tap each of the relevant
diagnostic criteria and generally differ in their degree of structure. Some widelyused instruments include:•

Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS)•

Development and Wellbeing Assessment (DAWBA)•

Diagnostic Interview Schedule for Children (DISC).

If the interest is in anxiety more specifically, then the Anxiety Disorders
Interview Schedule for Children (ADIS-C) (Silverman & Albano, 1996) hasa primary focus on these disorders. For very young children, the Preschool Age
Psychiatric Assessment (PAPA) is a useful instrument (Egger et al, 2006). Most
structured interviews involve separate interviews with the parents and the child (atAnxiety disorders

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IACAPAP Textbook of Child and Adolescent Mental Healthleast once the child is 8 years old or so) and the clinician is then faced with the taskof combining the information in some way.
Like most disorders of childhood, information from parents and children
about anxiety disorders commonly contains several discordant aspects. Clinicaljudgement and experience needs to be applied to determine which information
is more heavily weighted and how best to combine the information (see Chapter
A.3 for a detailed discussion of this issue). Anxious children are often thought to“fake good” (Kendall & Chansky, 1991) – in other words, to deny feeling anxious
or to provide answers that they think are socially acceptable. However, many
parents are also anxious (discussed below) and in some cases will exaggerate thechild’s difficulties due to their own distress. Hence, the interviewer needs to obtainsufficient detail to allow a judgement about which is the most accurate report andwhich aspects of the information may be inaccurate.
Clinically, distinguishing between specific disorders can be difficult. As
described above, it is important to determine the basic motivation behind particularbehaviours in order to identify the relevant diagnosis. For example, young children
who have a tantrum when their parents plan to go out may be doing so due tothe attention and benefits they receive, or to a fear of some negative occurrence
following separation. Clinically, once all behaviours, motivations, and diagnostic
criteria have been assessed and it has been determined that a child meets criteria
for two (or more) clearly distinct disorders, it is generally useful to determine
which of the disorders is principal (also referred to as primary). Most authors
conceptualise the principal disorder as the one that produces the greatest impact
and interference in the child’s life. Hence this disorder is usually the initial focus
in therapy. Most empirical evaluations of treatments for child anxiety are based onchildren who meet criteria for anxiety disorders as their principal disorder. In somecases, however, it may be more important to determine which disorder appears
to be the underlying or causal problem. For example, a child suffering depression,loneliness and victimisation because of their social anxiety may respond best if
the social anxiety is treated first, regardless of whether it is the primary condition.
In some cases, a particular problem may be expected to interfere with treatment
response and may therefore require initial attention, even if it is not the principal
disorder. For example, a child whose anxiety appears to be most interfering but
whose additional depression results in low motivation may need treatment of thedepression and motivation before they will be able to engage in treatment for the
anxiety.

Questionnaire assessment of child anxiety
The severity of anxiety or extent of anxiety symptomatology can bemeasured using several questionnaires. Most have demonstrated good psychometricproperties from around age 8 or 9 years and can be used up to middle or lateadolescence. From middle adolescence, adult measures of anxiety are usuallysuitable. Very few measures have been developed for younger children.
A few questionnaires contain subscales that each tap diagnostic-likeconstructs such as separation anxiety, social anxiety or generalised anxiety. Most ofthese questionnaires have parallel versions for the parent and child. These include:• Spence Children’s Anxiety Scale (SCAS) (free of charge and available inseveral languages)• Screen for Anxiety and Related Disorders (SCARED)• Multidimensional Anxiety Scale for Children (MASC).
A similar measure has recently been developed for preschool-aged children,
to be completed by their parents only – the Preschool Anxiety Scale, Revised (PAS-R)(free of charge and available in several languages).

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Several older measures aim to assess the overall degree of anxiousness more
broadly. These include:• Revised Children’s Manifest Anxiety Scale (RCMAS)• State Trait Anxiety Inventory for Children (STAIC)• Beck Anxiety Inventory for Youth.
A similar measure assessing internalising symptomatology completed byparents has also been developed for children at preschool age – Children’s Moods,
Fears and Worries (Bayer et al, 2006).
In some circumstances, more specific and detailed assessment of aparticular form of anxiety may be required. In these cases, a few measures tap into
specific aspects of anxiety including:••••Fear Survey Schedule for Children Revised (FSSCR)
Social Phobia and Anxiety Inventory for Children (SPAIC)
Social Anxiety Scale for Children - Revised (SASC-R)
Children’s Anxiety Sensitivity Index (CASI) (Silverman et al, 1991)

Finally, a few measures from our own centre may be of value since they tap
relevant aspects related to anxiety disorders. The Children’s Automatic Thoughts Scale(CATS) is designed to assess specific beliefs experienced by children and adolescentswith a variety of disorders. Two of the subscales are especially relevant to anxiety:beliefs related to social threat and physical threat. The remaining subscales assess
beliefs related to personal failure and hostility. The School Anxiety Scale -Teacher
Report (SAS-TR) provides a measure of children’s anxiety that can be completed
by the classroom teacher. This measure is an additional source of information thatcan flesh out a broader clinical picture of the anxious child. Finally, the Children’s
Anxiety Life Interference Scale (CALIS) has two parallel measures (one reportedby the child and the other by parents) that assess the extent to which the child’sanxiety impacts on the child’s and family’s life.

Click on the picture to view
the Centre for Emotional
Health’s website from
where the CATS, SAS-TR,
and CALIS, as well as the
PASR can be downloaded
free of charge. Some ofthese scales are available
in languages other thanEnglish.

RISK AND MAINTAINING FACTORS
Family transmission
Anxiety runs in families. First degree relatives of people with anxiety
disorders are at increased risk to also have anxiety as well as mood disorders. The
same is true more specifically for anxiety in children and adolescents. Anxious
children are considerably more likely to have parents with anxiety disorders andadults with anxiety disorders are more likely to have anxious children (Rapee etal, 2009). A similar relationship occurs more generally for temperament that is
related to anxiety (see below). Adults with anxiety disorders are more likely to havechildren who are highly inhibited and inhibited children are more likely to haveparents with anxiety and mood disorders (Rosenbaum et al, 1993).
One important finding is that family transmission of anxiety seems toshow some specificity. In other words, several studies have shown that people
with a particular anxiety disorder (e.g., social phobia) are more likely to have first
degree relatives with that same disorder (social phobia) than with other anxiety
disorders. This is different from research on genetic factors that has not shownspecificity (see below). Of course, family transmission can reflect both genetic andenvironmental influences, so it is tempting to speculate that genetic transmission
confers a broad, general risk, while family environment may shape that risk into
specific manifestations.

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Genetic factors
There is little doubt that anxiety disorders are heritable. Best estimatessuggest that around 40% of the variance in anxiety symptoms and in diagnosesof anxiety disorder is mediated by genetic factors. This estimate is even higher if
one looks at stability of anxiety over time. Slightly less research – but with similarfindings – has been done on anxiety specifically during the childhood years. Twin
studies of anxiety in children indicate that around 30% to 40% of the variancein symptoms and disorders can be attributed to heritability (Gregory & Eley,2007). There is some evidence (albeit with limitations) that heritability estimates
for temperamental risk for anxiety (e.g., inhibition) is slightly higher (Rapee &Coplan, 2010). As mentioned above, genetic risk across anxiety disorders appears
to be largely general and seems to primarily load on a very broad factor such as
general neuroticism (Gregory & Eley, 2007).
Work on specific genes underlying anxiety disorders is less extensive and,to date, no evidence exists linking any individual gene specifically to anxiety. Many
candidates have been explored; the most widely studied being the promoter regionof the serotonin transporter gene (5HTTLPR). However, polymorphisms on thisgene have been associated with different disorders and it is unlikely that it would
play a specific role in anxiety. In fact, one theory states that having two short alleleson the 5HTT gene may generally increase an individual’s overall responsiveness toenvironmental events (both positive and negative) (Belsky et al, 2009).

Temperamental factors
Temperamental risk for anxiety is probably the best studied and mostclearly established risk factor (Fox et al, 2005; Rapee et al, 2009). A variety of similar
temperaments have been associated with child anxiety including: behavioural
inhibition, withdrawal, shyness, and fearfulness. I will refer to these various
temperaments in this section under the general term inhibition. Extensive research
has shown that very young children who are identified as high on inhibition are
at greater risk for later anxiety disorders. As described above, research has also
linked inhibition with anxiety disorders in first degree relatives. The most common
assessment of inhibition occurs in children from around two to five years of age.
This may be done via questionnaires or direct observation. Common features ofinhibition include:• Withdrawal in the face of novelty• Slowness to warm up to strangers or peers• Lack of smiling• Close proximity to an attachment figure• Lack of talk
• Limited eye contact or “coy” eye gaze
• Unwillingness to explore new situations.
Children who show these characteristics during preschool age are two tofour times more likely to meet criteria for anxiety disorders by middle childhoodand this increased risk has been shown to continue at least into adolescence (Foxet al, 2005). Some evidence has also indicated that infants (aged 3-6 months)
who show high levels of arousal and emotionality are at greater risk to showhigh inhibition by two to five years. Therefore, it seems to be possible to identify
increased risk for anxiety from a few months of age (Kagan & Snidman, 1991).
Theoretically, the main complication with this research is the extensive
overlap between the constructs of inhibition and anxiety disorders. Thus, one
could argue that inhibition is simply a less clear version or an early manifestationof an anxiety disorder. There is some evidence that inhibition and disorder have

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Jerome Kagan, professorof psychology at Harvard
University, is one of thescholars who contributed
to developing the conceptof temperament, which
he defined as stablebehavioural and emotional
reactions that appear earlyin life. He described two
types of temperament:
inhibited and uninhibited.
The former applies tochildren who are shy,timid, socially withdrawn
and fearful, while the latter
refers to children who are
outgoing, sociable anddaring.

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IACAPAP Textbook of Child and Adolescent Mental Healthsome unique features and thereby represent distinct constructs but the issue is far
from settled (Rapee & Coplan, 2010).

Parent and family factors
Given the evidence for the transmission of anxiety within families describedabove, it has commonly been assumed that parents and the family environment
must contribute to the development of anxiety disorders. However, evidence has
been difficult to obtain and data have not been entirely consistent. The mostextensive research has focussed on parenting and parent-child interactions.
There is now little doubt that the parenting of anxious children ischaracterised by overprotection, intrusiveness and, to a lesser extent, negativity(McLeod et al, 2007). Whether this relationship is causal is much harder todetermine and, to date, there has been very little examination of this issue. Theories
argue that the parent-child relationship is likely to reflect cyclical interactions. Thatis, inhibited children are likely to elicit overprotection from their parents and,in turn, overprotective parenting is likely to lead to further anxiety (Hudson &Rapee, 2004; Rubin et al, 2009). Few longitudinal studies have addressed thisrelationship, but at least some evidence is consistent with this theory (Edwards etal, 2010). There is also some evidence that an interaction between the serotonintransporter gene and parenting predicts later anxiety in young children (Fox et al,2005).

It seems that fear of
strangers can be increased
through an interaction
between the infant's
temperament and themother's overt indicators offear.

It has often been assumed that anxious parents increase risk for anxiety
in their children by modelling their own fears and coping strategies. This theory,
however, has received very little examination. The main research has come fromlaboratory studies with very young children. Research has shown that children aged
around 6-18 months can learn to fear and avoid a novel stimulus by observing theirmothers acting in a fearful manner. More importantly, socially anxious mothers
have been shown to transmit a fear of strangers to their infants in this way, andthe extent of fear that the infant develops depends partly on the pre-existing levelof inhibited temperament that the infant displays (de Rosnay et al, 2006). Thus,
it seems that fear of strangers can be increased through an interaction between
the infant’s temperament and the mother’s overt indications of fear. Among older
children it has been shown that verbally transmitted information about danger
can increase fear of particular cues. For example, when children are presented withinformation about a novel cue that suggests the cue might be dangerous, they show
increases in fear, physiological arousal, threat beliefs, and avoidance of the cue thatcan last for several months (Field, 2006).
Finally, a key question is whether disturbed family environments play arole in the development of child anxiety. There has been a wealth of longitudinal
research examining the long-term impact of family distress and violence, parent
divorce or separation, and sexual and physical abuse, although little of this work
has focussed clearly on anxiety disorders. Overall, it appears that sexual abuse –and to a lesser extent physical abuse and family violence – can increase anxiousness
in children. However, this increase is likely to be temporary and it is not clear
whether these factors contribute significantly to the development of longer-term
anxiety disorders. More importantly, it is clear that these factors are relatively nonspecific and increase risk for a wide variety of child psychopathology, probably leastof all for anxiety disorders (Rapee, 2012).

Life events
Although there has been a large body of research examining the role ofnegative life events in the onset of adult anxiety disorders (mostly agoraphobia),
there has been very little work looking at life events in childhood anxiety. This may
be because child anxiety often develops in a background of inhibited temperament

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IACAPAP Textbook of Child and Adolescent Mental Healthand a clear and sudden onset of the disorder is relatively rare. What research has
been conducted suggests that anxious children do report a greater number andimpact of negative life events than do children without anxiety disorders. While
it is possible that this difference reflects cognitive and reporting biases, at least
some work has demonstrated this difference using interviews with parents andidentifying corroborating evidence (Allen et al, 2008). Nevertheless, demonstratingthat anxious children have more negative life events than non-anxious children
does not mean that these events necessarily cause or trigger their anxiety. Indeed,
the data suggest that the greatest difference is found on so-called “dependent” life
events. Dependent events are ones that might be the result of the child’s behaviour(e.g., doing badly in a test might be a result of the child not studying). Thus, it isvery possible that child anxiety leads to more negative life events, perhaps due tothe worry and avoidance associated with the anxiety. Of course, it is also possiblethat this increased stress, in turn, helps to maintain and even increase the anxiety.
One specific form of life event that has received particular attention isbullying and teasing. There is considerable evidence that anxious children are more
likely to be teased and bullied than non-anxious children and that they are often
neglected or even rejected by their peers (Juvonen & Graham, 2014). Once again,
the direction of causation is unknown but it is very likely that anxious children
elicit teasing from others due to their behaviours; in turn, it is likely that teasing
will further enhance their anxiety.

Cognitive biases
Anxious children report heightened beliefs and expectations of threat. To
some extent this is a reflection of the diagnosis, but it is also argued to represent a
core maintaining feature. Although there is considerable overlap, to some extent
the threat expectancies are specific. That is, socially phobic children are more likely
to have increased expectancies for social threat (e.g., “other kids won’t like me”),
children with separation anxiety will have increased expectancies for physicalthreat (e.g., “my parents will get hurt”), and so on. Evidence suggests that thesethreat beliefs are greater among anxious children than among children with otherpsychopathology and that they decrease with successful treatment (Schniering& Lyneham, 2007). Whether they are causally related to the onset of anxiety or
simply reflect the anxiousness is not clear.
Research has also focused on the ways in which anxious children process
threatening information (Muris & Field, 2013). As has been shown in adults,
anxious children have both a bias in attention toward threat and a bias to interpretambiguous information in a threat-consistent manner. Some research has shownthat these biases decrease with successful treatment.

TREATMENT
Psychopharmacology
Pharmacological management of anxiety in children has typically focussed
on the use of selective serotonin reuptake inhibitors (SSRIs). Several studies havedemonstrated significant efficacy of SSRIs such as fluoxetine and sertraline in the
management of broad-based anxiety disorders, although most studies have primarily
focussed on treatment of OCD (Ipser et al, 2009). Little difference has been shown
between specific agents, although paroxetine is not recommended in this age groupand there is some suggestion that Venlafaxine has lower efficacy and acceptability(Uthman 2010). Treatment has generally lasted 10-15 weeks. Outcome results
indicate that 50% to 60% of children are considered treatment-responders at theend of treatment compared with around 30% of those on placebo. Unfortunately,
the longer-term maintenance of gains has rarely been investigated, but there isAnxiety disorders

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Click on the picture to hear
Eli R Lebowitz PhD talk about
CBT for childhood anxiety
disorders (13:14 minutes)

11

IACAPAP Textbook of Child and Adolescent Mental Healthsome hint in the literature that medication effects may level off after around 8
weeks (Ipser et al, 2009). Adverse medication events are relatively infrequent but
do occur and up to 7% of anxious children on SSRIs discontinue due to side
effects. Suicidality needs to be monitored in all young people taking an SSRI (formore details on pharmacological treatment see Chapter A.8 and Table A.8.1).

Skills-based programs
Most evidence-based psychological treatment for childhood anxiety falls
under the broad category of cognitive-behavioural or skills-based treatment. The
fundamental basis is teaching the child (and sometimes the parents) specific skills
to help manage the child’s anxiety. Most treatments consist of comprehensive
packages or combinations of techniques. Specific treatment techniques include:• Psychoeducation• Relaxation• In vivo exposure• Contingency management• Parent training• Cognitive restructuring• Social skills and assertiveness training

Results indicate that 50%
to 60% of children are
considered diagnosis-free atthe end of treatment (skillsbased or CBT programs)
and this figure typicallyincreases to 70%-80% up to
12 months following the endof treatment

Treatment programs typically last 8-15 weeks of around 1-2 hours persession and have been delivered in either group format or individually. Results
indicate that 50% to 60% of children are considered diagnosis-free at the endof treatment (James et al, 2015) and this figure typically increases to 70%-80%
up to 12 months following the end of treatment. A few studies have indicatedmaintenance of treatment gains up to 6-8 years following treatment (e.g., Kendall
et al, 2004).
A number of studies have tried to identify factors that may influence
treatment efficacy. There is some evidence that individual treatment delivery may
produce slightly larger effects than treatment delivered in a group (Reynolds et al,2012). A more important issue that has received some attention is the extent towhich it is necessary to include parents in treatment and to teach them specificskills. Evidence on this issue is mixed but generally indicates few benefits ofincluding parents as active participants in the treatment (Reynolds et al, 2012).
However, studies that have addressed this issue have rarely taken the age of thechild into account. More importantly, studies differ widely in the ways in which
parents have been included in treatment programs and this has rarely been
considered in reviews of the literature. In one large reanalysis of data, teaching
parents specific skills in parenting or methods to help their child outside therapy,
led to significantly better outcomes three months following the end of treatment
than other parental inclusion (Manassis et al, 2014).
Another relevant question is the influence of comorbid diagnoses ontreatment effects. Surprisingly, the majority of research to date has failed to showthat treatment response is worse for anxious children with comorbid disorders.
In other words, anxious children seem to respond equally well to skills-based
treatment packages even if they have additional difficulties with anxiety, depression,
or externalising problems (Ollendick et al, 2008). Having said that, there is mixed
evidence for depression; a few studies have suggested that comorbid depression may
reduce treatment response (Rapee et al, 2009). A recent study from our own clinic
has shed a little more light on this issue. Based on our data, it appears that having
a comorbid disorder does not influence the degree of change across treatment but
does influence the endpoint. Because children with comorbid disorders (especiallycomorbid externalising disorders and depression) typically have more severe

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IACAPAP Textbook of Child and Adolescent Mental Healthanxiety to begin with, the point they reach at the end of treatment is generally
not as good as children without comorbid disorders, although the rate of change
across treatment is very similar. Some research has also begun to show that children
with high functioning autism and comorbid anxiety also respond very well to thetreatment of their anxiety (Moree & Davis, 2010).
Few other predictors of treatment response have been found. There havebeen hints that parent psychopathology – both parent anxiety and depression –predicts worse outcome, but some studies have failed to show this effect. Other
factors such as marital status, parent education, and family size appear to havelittle effect. Some intriguing research has shown that genetic status might predict
treatment response. Children with short alleles on the 5HTTLPR gene showed abetter response to treatment at follow-up than did children with two long alleles(Eley et al, 2012). However, a later study failed to replicate this effect (Lester et al,2016). Finally, consistent evidence has emerged that children with social anxiety
disorder show poorer response to treatment than children with other anxiety
disorders (Hudson et al, 2015). The reasons for this difference are not clear but it
is possible that social anxiety will require additional treatment elements.

Low intensity interventions
A growing body of work is demonstrating the efficacy of treating anxious children
using methods that require considerably fewer therapist resources than traditional
face-to-face treatment (Rooksby et al, 2015). This form of treatment, often
referred to as low intensity, is usually delivered either by written material or overthe internet. Programs of this type usually follow skills-based principles, but the
information is delivered to either the parent (for children) or to the young person
directly (for adolescents) via printed or electronic means. Most programs include
some support from a therapist, often over the telephone, and this has been shown
to produce larger effects than pure self-help.

A program example: Cool Kids
There are several skills-based treatment packages for the management ofanxiety disorders in young people and most contain very similar components. As
Table F.1.2 Sessions and components of the Cool Kids program.

SessionCoverage - Child

Coverage - Parents

1

Psychoeducation

Psychoeducation and treatment rationale

2

Cognitive restructuring

Cognitive restructuring for both parent and child3

Cognitive restructuring practice

Cognitive restructuring practiceChild management skills

4

In vivo exposure and development of hierarchies

In vivo exposure and development of hierarchies

5

Dealing with difficulties in exposure

Dealing with difficulties in exposure

6

Practice exposure and cognitive restructuring

Practice exposure, cognitive restructuring and childmanagement

7

Introduce assertiveness and social skills

Ways to increase assertiveness and social skills

8

Teasing and bullying

Teasing and bullying

9

Practice and review

Practice and review

10

Practice, review and relapse prevention

Practice, review and relapse prevention

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IACAPAP Textbook of Child and Adolescent Mental Health

Table F.1.3 Treating childhood anxiety disorders in practice•First line treatment: Low-intensity treatment – including use of books(bibliotherapy), CD’s or internet programs (e-therapy). May not be recommended incases of highly urgent need (e.g., chronic school refusal) or high risk (e.g., suicidal
ideation), or in cases of especially poor parent-child relationships•

If unwilling to attempt low intensity – then low-intensity is not recommended– or patient does not improve with low-intensity treatment, suggest traditional
CBT or skills-based treatment with a qualified practitioner in all cases, with the
exception of patients who refuse skills-based treatment or CBT is not available•

If a patient does not improve after a treatment program delivered by a skilful
clinician for long enough (12-20 weeks), refuses skills-based treatment or CBT is notavailable, consider medication•

When patients are treated with medication – alone or in combination with CBT(multimodal treatment) – keep in mind that:−

No medication is approved by the US Food and Drug Administration (FDA)
for any anxiety disorder in patients younger than 6 years of age (see Table
A.8.1). Overall, avoid medication in younger children (i.e., younger than 10
years of age).

−

While there is some evidence of effectiveness for some SSRIs for several
anxiety disorders (e.g., OCD, social phobia, generalised anxiety) (seeTable A.8.1), they are formally approved by the FDA in the US only for thetreatment of OCD (that is, they are used “off label” for anxiety disorders
other than OCD). This may not be the case in other countries.

−

Avoid using benzodiazepines. While benzodiazepines reduce anxiety
in the short term, there is no evidence they are effective treating thedisorder. They have more side effects in young people and potential for
dependence.

−

Monitor side effects, particularly suicidality.

−

Review regularly, initially weekly, later on monthly.

−

Monitor response using an appropriate rating scale and switch to another
SSRI if there is no improvement or, if not already tried, add CBT.

Click on the picture to hear
Professor Rapee talk aboutanxiety disorders (06:08)

an example, I will describe our own program, Cool Kids. Cool Kids is a manualised
treatment program for anxious young people aged 7 to 17 years. There is a detailed
set of guidelines for therapists that is supported by workbooks for the parents
and the young person. Different workbooks and a slightly different structure areused for children (7-12) and adolescents (13-17). There are also modified versions
for use with children with autism, children who are chronically victimised, foradolescents with comorbid anxiety and depression, for children and adolescentswith unexplained medical symptoms, and for families who are unable to attend aclinic for face-to-face treatment (low intensity).
Treatment using Cool Kids typically comprises 10 sessions over 12 weeks.
Parents are an integral component and are seen at all sessions when treatment is forchildren but have a reduced involvement when treatment is for adolescents. The
program can be delivered in either a group or individual format. Sessions typicallylast 60 minutes when delivered individually and 120 minutes when delivered asa group. There are separate components covered with children and parents. The
sessions and components of Cool Kids are shown in Table F.1.2.
Overall efficacy for Cool Kids is good (Mychailyszyn, 2017). We generally
include any child with an anxiety disorder as their principal (most interfering)

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IACAPAP Textbook of Child and Adolescent Mental Healthdisorder as well as children with OCD; we rarely exclude children due tocomorbidity. Our data indicate few differences in outcome aside from the usual
poorer outcomes for young people with social anxiety disorder and those withcomorbid depression (Hudson et al, 2015; Rapee et al, 2013). Therapists withtraining in clinical psychology, experience in working with young people, andskills in the delivery of cognitive behavioural treatments are able to run the
program; training workshops are regularly conducted through our centre and overthe internet, and we have a system of accreditation. The program is available in a
number of languages and is used around the world.

PREVENTION AND EARLY INTERVENTION
Given the growing knowledge of risk factors for the development ofchild anxiety, there is rising interest into the possibility of very early intervention
and prevention. Growing recognition of the public health implications of
psychopathology has increased the realisation that a large proportion of children
who are high in anxiousness but do not meet criteria for an actual disorder
may nevertheless be suffering and endure restrictions on their lives. As a result,programs for prevention and early intervention of anxiety are now being evaluated(Lyneham et al, 2014). These programs have covered all levels of prevention:
universal, selective and indicated.
Several large trials have demonstrated the efficacy of anxiety management
programs applied universally across sub-populations, most commonly delivered
via schools. These programs typically cover similar skills to those found inclinical packages including education, relaxation, cognitive restructuring, and invivo exposure; often they include additional skills such as communication andproblem-solving. Therefore, they may be better thought of as broad emotional
health programs that aim to teach young people ways of managing distressing
emotions. Results have mostly indicated reductions in anxiety, usually with small
effect sizes (Werner-Seidler et al, 2017). Given that these are universal programs
and are not targeting high risk groups, large effects are not expected but even small
effects across an entire population are meaningful.
Selective anxiety programs refer to those that target children who reportmoderate to high symptoms of anxiety but do not necessarily meet criteria for adisorder. The presumption is that these children are at increased risk to develop
disorders in the future and hence teaching them anxiety management skills provides
a clear method of prevention. However, even if they do not go on to develop
anxiety disorders, the low to moderate distress and life interference experienced
by these children makes them a valid target for skills training, especially giventhat very few seek professional help. As with universal programs, the majority ofthese interventions have used school-based populations. There are many methodsof selecting children with high levels of anxiety but most trials so far have used a
combination of student self-report and teacher report. Once again, the content ofthese programs is very similar (or identical) to that of clinical treatment programs.
Results have mostly indicated significant reductions in anxiety followingintervention, generally with small to moderate effect sizes (Werner-Seidler et al,2017).
Finally, a few studies have begun to investigate indicated programs for theprevention of anxiety – i.e., programs aimed at children scoring high on anxiety
risk factors. Targeted children have most commonly been selected on the basis ofhigh levels of temperamental inhibition, but high parent anxiety has also been used
to identify relevant children. In the only longer-term study to date, we developed
a modified version of Cool Kids called Cool Little Kids. The program is aimed
at parents of inhibited preschool-aged children and comprises 6 group sessions.
Components are mostly aimed at reducing parent overprotection and encouraging

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IACAPAP Textbook of Child and Adolescent Mental Healthin-vivo exposure for the children. By age 15, children whose parents attended
the program showed significantly fewer anxiety and mood diagnoses compared tochildren whose parents received no training (Rapee, 2013). Delivery of Cool Little
Kids over the internet has also shown promising effects (Morgan et al, 2017).

CONCLUSION
The past two decades have seen a tremendous expansion in our knowledgeof the development and management of childhood anxiety disorders. Many key
issues remain to be evaluated and we still have a long way to go but we are currently
at a point where anxious children are recognised and can be thoroughly assessed.
There are now treatments that work for the majority of patients and programs are
beginning to be devised to prevent the development of anxiety. Several promisingareas of research are just starting to grow and will hopefully provide further
advances in the coming years. These include:•

Better understanding of risk factors for anxiety through longitudinal
research•

Closer evaluation of gene-environment interactions in thedevelopment of anxiety•

More understanding of peer interactions in anxiety and theirinfluence on its development•

Better methods of disseminating treatments, through internet anddistance (tele-health) programs•

Evaluation of novel improvements to treatment such as the use ofmemory consolidation agents or cognitive bias modification.

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Beesdo-Baum K, Knappe S (2012). Developmental
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Costello E, Mustillo S, Erkanli A et al (2003). Prevalence anddevelopment of psychiatric disorders in childhood andadolescence. Archives of General Psychiatry 60:837-844.

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Edwards SL, Rapee RM, Kennedy S (2010). Prediction ofanxiety symptoms in preschool-aged children:
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Egger HL, Erkanli A, Keeler G at al (2006). Test-retest reliabilityof the Preschool Age Psychiatric Assessment (PAPA).
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Eley TC, Hudson JL, Creswell C et al (2012). Therapygenetics:
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Field AP (2006). Is conditioning a useful framework forunderstanding the development and treatment ofphobias? Clinical Psychology Review 26:857-875.
Fox NA, Henderson HA, Marshall PJ et al (2005). Behavioral
inhibition: Linking biology and behavior within adevelopmental framework. Annual Review of Psychology
56:235-262.

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IACAPAP Textbook of Child and Adolescent Mental HealthFox NA, Nichols KE, Henderson HA et al (2005). Evidence
for a gene-environment interaction in predicting
behavioral inhibition in middle childhood.
Psychological Science 16:921-926.
Gregory AM, Eley TC (2007). Genetic influences on anxiety inchildren: What we’ve learned and where we’re heading.
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Hudson JL, Rapee RM (2004). From anxious temperament todisorder: An etiological model of generalized anxiety
disorder. In RG Heimberg, CL Turk & DS Mennin(Eds), Generalized Anxiety Disorder: Advances in
Research and practice. New York: Guilford Publications
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Hudson JL, Rapee RM, Lyneham HJ et al (2015).
Comparing outcomes for children with different
anxiety disorders following cognitive behaviouraltherapy. Behaviour Research and Therapy 72: 3037.
Ipser JC, Stein DJ, Hawkridge S et al (2009).
Pharmacotherapy for anxiety disorders inchildren and adolescents. Cochrane Database of
Systematic Reviews (Issue 3): CD005170.
James AC, James G, Cowdrey FA et al (2015). Cognitive
behavioural therapy for anxiety disorders inchildren and adolescents. Cochrane Databaseof Systematic Reviews(2), Art.No.: CD004690.
DOI: 10.1002/14651858.CD004690.pub4
Juvonen J, Graham S (2014). Bullying in schools: The
power of bullies and the plight of victims.
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Kagan J, Snidman N (1991). Infant predictors ofinhibited and uninhibited profiles. Psychological
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Kendall PC, Chansky TE (1991). Considering cognitionin anxiety-disordered children. Journal of Anxiety
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Kendall PC, Safford S, Flannery-Schroeder E et al(2004). Child anxiety treatment: Outcomes inadolescence and impact on substance use anddepression at 7.4 year follow-up. Journal ofConsulting and Clinical Psychology 72:276-287.
Lester KJ, Roberts S, Keers R et al (2016). Nonreplication of the association between 5HTTLPR
and response to psychological therapy for childanxiety disorders. The British Journal of Psychiatry
208:182-188. doi:10.1192/bjp.bp.114.154997
Lyneham HJ, Hudson JL, Rapee RM (2014). Preventionof anxiety disorders. In T. Ehring & P. M.
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Manassis K, Lee TC, Bennett K et al (2014). Types ofparental involvement in CBT with anxious
youth: A preliminary meta-analysis. Journal ofConsulting and Clinical Psychology 82:1163-1172.

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McLeod BD, Wood JJ, Weisz, JR (2007). Examining theassociation between parenting and childhood
anxiety: A meta-analysis. Clinical Psychology
Review 27:155-172.
Moree BN, Davis TE III (2010). Cognitive-behavioral
therapy for anxiety in children diagnosed with
autism spectrum disorders: Modification trends.
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Morgan AJ, Rapee RM, Salim A et al (2017). Internetdelivered parenting program for earlyintervention of anxiety problems in young
children: A randomized controlled trial.
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org/10.1016/j.jaac.2017.02.010
Muris P, Field A (2013). Information processing biases.
In Essau, CA, Ollendick TH (Eds) The
Wiley-Blackwell Handbook of The Treatmentof Childhood and Adolescent anxiety WileyBlackwell; pp 141-156.
Mychailyszyn MP (2017). “Cool” Youth: A systematic
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Ollendick TH, Jarrett MA, Grills-Taquechel AE etal (2008). Comorbidity as a predictor andmoderator of treatment outcome in youth with
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Rapee RM (2012). Family factors in the development andmanagement of anxiety disorders. Clinical Childand Family Psychology Review 15:69-80.
Rapee RM (2013). The preventative effects of a brief,
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IACAPAP Textbook of Child and Adolescent Mental HealthReynolds S, Wilson C, Austin J et al (2012). Effectsof psychotherapy for anxiety in children andadolescents: A meta-analytic review. ClinicalPsychology Review 32:251-262.
Rooksby M, Elouafkaoui P, Humphris G et al (2015).
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51:30-47.

Appendix F.1.1(J M Rey)

SELF-DIRECTED LEARNING AND SELF-ASSESSMENT EXERCISES
F.1.1 Please list five (5) features ofinhibited temperament
F.1.2 Write a one-page essay about the
topic “anxiety runs in families”
F.1.3 Discuss the pros and cons ofinvolving parents in skills-based programs.
F.1.4 “There was a feeling of dreadthat would last for weeks; I would
feel nauseous and sick as the dateapproached; light headed and shaky when
thinking about what I needed to do, andas the day got closer I would get sweaty,
flushed, extremely unfocused and get a dry
mouth or salivate too much, and I needed
to go to the toilet too frequently which was

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F.1

quite unpleasant! During a performance
I would lose control of my fingers andmouth, this would affect the sound I had
worked so hard to make, the notes would
come out a jumbled mess and it felt like I
had completely lost control of the actionsof my body” (https://www.adavic.org.au/
PG-personal-stories-performance-anxiety-byshelley.aspx).
These symptoms are suggestive of which
one of these diagnoses?
A. Generalized anxiety disorder
B. Social phobia
C. Panic disorder
D. Obsessive compulsive disorder
E. Separation anxiety disorder18

IACAPAP Textbook of Child and Adolescent Mental Health

F.1.5 Physical symptoms which tend tooccur when separation is anticipated (e.g.,
vomiting, diarrhoea, stomach ache) are
more commonly seen in:

F.1.8 Pharmacological (SSRIs) treatment
for anxiety disorders is typically indicated:
A. As a first line treatment

A. Generalized anxiety disorder

B. When patient does not improve with
CBT

B. Social phobia

C. In older children

C. Panic disorder

D. When there is comorbidity

D. Obsessive compulsive disorder

E. Never for these anxiety disorders

E. Separation anxiety disorder
F.1.6 When compared with other anxious
children, those with social phobia are
specifically more likely to:
A. Repeatedly seek reassurance fromparents about fears
B. Worry too much about family finances
C. Worry about others thinking they areunattractive, stupid, unpleasant, or odd
D. Avoid public transport, enclosed
spaces, cinemas, hairdressers, or
heavy traffic
E. Repeat behaviors again and again
F.1.7 While it is often difficult todetermine exactly when an anxiety
disorder first begins, it is estimated thatanimal phobias, a type of specific phobia,
start on average around what age:
A. 6-7 years
B. 8-9 years
C. 10-11 years
D. 12-13 years

F.1.9 “One day a friend at school told methat the Black Hole was coming to earth. At
first, I just shrugged this off, however later
when I was alone, thoughts of this would
start to take over my mind. Even though
my Mum discussed all my fears with me,
assuring me that these things were untrue,
it still did not stop me from fearing theworst to the point I was starting to see it in
the sky. Well I thought I did. It was a cloudshaped as the Black Hole. It was when I
was having a simple hair cut that I began
to realize something was really not right.
My Mum was cutting my fringe when myeyesight went blurry, my heart began topound in my chest, I couldn’t breathe. My
hearing was fading and I couldn’t thinkproperly. Mum took me to bed and gave
me a healthy muesli bar. Mum thought mysugar levels were low. They were perfectly
fine, but I wasn’t.” (https://www.adavic.org.
au/PG-personal-stories-the-tale-of-an-elevenyear-old-when-my-panic-attacks-becamereality.aspx)
These symptoms are suggestive of which
one of these diagnoses?
A. Generalized anxiety disorder

E. 14-15 years

B. Social phobia
C. Panic disorder
D. Obsessive compulsive disorder
E. Separation anxiety disorderAnxiety disorders

F.1

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IACAPAP Textbook of Child and Adolescent Mental HealthANSWERS
F.1.1

Answer: see page 10.

F.1.2

Answer: see page 10.

F.1.3

Answer: see page 12.

F.1.4

Answer A. See Table F.1.1

F.1.5

Answer E. See Table F.1.1

F.1.6

Answer C. See Table F.1.1

F.1.7

Answer A. See Page 6

F.1.8

Answer B. See Table F.1.3

F.1.9

Answer C. See Table F.1.1

Anxiety disorders

F.1

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