Fear refers to the emotional response to real or perceived immediate threat. Anxiety refers to the anticipation of future threat. Phobia refers to being fearful or anxious about or avoidant of a certain object or situation. There is no specific cognitive ideation.
There are four symptoms of anxiety:
Physiological symptomsThe purpose of anxiety is to alarm one of danger (1), prepare the body to act quickly (2) and keep distance from the danger (3). There is no strict boundary between typical and deviant anxiety. Therefore, the four d’s need to be evaluated when assessing anxiety.
What a child is afraid of changes with age. Children may be more afraid of animals due to their magical thinking. They may be afraid of the dark because of their inability to control it. At seven or eight years old children start to become more concerned with the future.
There is an increase in the prevalence of any anxiety disorders from the age of 11. There is a strong decline in separation anxiety disorder after the age of 10. For phobias, the prevalence can reach up to 16% in adolescence.
Children who suffer from anxiety disorders will be clinging (1), show physical complaints (2), have sleep problems (3), concentration problems (4), avoid certain situations (5), demonstrate a lot of ‘just in case’ behaviour (6), feel small (7), get angry (8), get easily upset (9), demonstrate perfectionism (10), stay home from school (11), lie (12) and alarm adults (13). There is comorbidity between ADHD and anxiety disorders.
Behavioural inhibition refers to inhibited behaviour. As an infant, there is high reactivity to stimuli (e.g. crying). In preschool, these children do not approach strangers (1), stare at strangers (2) and stays close to the mother (3). Modelling behaviour is stronger in the same-sex parent.
There are several risk factors for anxiety disorders:
Risk factors in the microsystem include a lot of parental control and rejection. Risk factors in the chronosystem include negative life events (e.g. domestic violence; bullying). School can also be a risk factor as several aspects increase the risk for anxiety disorders:
It is important to assess why school refusal developed. This can be done by making a functional analysis (i.e. determining the function of school refusal).
There are several protective child factors for anxiety:
There are also several protective system factors for anxiety:
There are three routes to anxiety:
There are three types of biases.
A cognitive bias is typically implicit and can maintain anxiety as it leads to avoidance. Avoidance provides relief from the anxiety-inducing object in the short-term but leads to an increase in anxiety over the long-term as there is no development of coping with anxious situations. A personal fable refers to the tendency to believe that no one has ever experienced what one is experiencing. Imaginary audience refers to the idea that everyone is looking at you. This may be relevant to the development of social anxiety disorder.
There is comorbidity between anxiety and depression and this can be explained by the tripartite model. This states that there are three factors that are relevant in both disorders.
According to the model, both disorders are characterized by a lot of negative affectivity. However, anxiety also has increases in physiological hyperarousal and depression has a decrease in positive affectivity.
It is essential to adapt language use to the client in psychoeducation. There are several components of psychoeducation:
The goal of psychoeducation is to visualize the anxiety symptoms and elucidate how they are related. To do this, one can make an anxiety circle. This refers to a circle of how anxiety can be maintained by the stressors and the current behaviours. It is also possible to focus on cognition and how faulty thinking patterns can lead to anxiety (e.g. worrying as a coping mechanism; underestimating self-competence).
One treatment for anxiety disorders is systematic desensitization and it occurs in several steps:
Disorder | SEPARATION ANXIETY DISORDER |
Clinical description | Developmentally inappropriate intense feelings of distress upon separation of the caregiver lasting for at least four weeks. The disorder manifests itself before the age of 18. 6 is considered early onset. School refusal is common. |
Symptoms | At least three of the following for at least four weeks:
Repeated physical complaints when separation is anticipated. |
Course | It is more frequent in females and is comorbid with GAD, depression and somatic complaints. It may be a precursor for increased risk for disorders in adulthood. |
Aetiology | Mothers often have a history of anxiety disorders. Overprotectiveness and reinforcement of the child’s avoidance behaviours can maintain the disorder. |
Assessment and treatment | Treatment includes cognitive behavioural interventions (e.g. Coping Cat), focussing on coping skills or exposure. |
Disorder | SELECTIVE MUTISM |
Clinical description | A reluctance to verbalize when expected lasting at least one month. It is not the response to weak language skills or a speech problem. |
Course | Children often outgrow it but it can be a risk factor for social anxiety disorder. |
Aetiology | The onset is associated with the beginning of formal schooling. Negative affectivity (1), behavioural inhibition (2), parental history of shyness (3), social isolation (4) and indicators of social anxiety are risk factors (5). |
Assessment and treatment | Treatment includes behavioural methods (1), systematic desensitization (2) and modelling (3). |
Disorder | PHOBIAS AND FEARS |
Clinical description | These children experience a persistent and significant fear of an object or place that does not have a reasonable basis. There is frequent avoidance and exposure may elicit strong physiological responses. The focus of the fear is the anticipation of harm and there is a strong desire to escape. |
Symptoms | This includes excessive reactions to encountering a feared object or situation and can include the following:
|
Course | More females than males have phobias. Situation-specific phobias develop later than phobias related to environmental concerns. The number of fears decreases with age but worries tend to escalate. |
Aetiology | Anxious attachment (1), family characteristics (2), exposure to conditioning experiences (3), parent psychopathology (4), family communication styles (5), parenting practices (6) and attachment history are risk factors. Protective behaviours may lead a child to not learn how to cope with distressing circumstances. |
Assessment and treatment | Treatment includes systematic desensitization (1), modelling (2), reinforced practice (3) and exposure (4). In-vivo exposure is most effective although the models can be videotaped. |
Disorder | SOCIAL ANXIETY DISORDER |
Clinical description | A pervasive fear of embarrassment or humiliation that leads to avoidance of social or performance situations. The fear must be present in front of peers as opposed to only in front of adults. |
Symptoms | In situations where people feel that they may be scrutinized excessive fear and anxiety may be:
|
Course | The onset is typically in adolescence and there is an increased risk for a lower quality of life and school dropout. People often do not seek treatment. It is more common in children with GAD and their GAD is often more severe. |
Aetiology | There typically is evidence of normal social interaction with familiar people and pervasive fear across situations. Parental communication (1), attachment (2), parenting style (3), first-degree relatives with social anxiety disorder (4) and behavioural inhibition (5). People with behavioural inhibition typically experience more social rejection. |
Assessment and treatment | Treatment includes systematic desensitization (1), exposure (2), modelling (3), reinforced practice (4) and social skills training (5). |
Disorder | PANIC ATTACKS |
Clinical description | A sudden overwhelming fear that penetrates thoughts, feelings and sensations. The attacks last about 10 minutes. |
Symptoms | It consists of at least four of the following symptoms:
|
Course | It is more common in adolescents and age of onset is typically between the age of 15 and 19. It can be triggered by specific phobias or can be the response to separation anxiety disorder. |
Aetiology | Negative affect (1), anxiety sensitivity (2), separation anxiety (3) and other anxiety and depressive disorders (4) are a risk factor. Panic attacks may occur from the interaction between temperament and attachment issues. It may also be the result of misinterpretation of bodily sensations. |
Disorder | PANIC DISORDER |
Clinical description | A persistent fear of recurrent panic attacks. |
Symptoms | In the month after a panic attacks, the following symptoms are demonstrated:
|
Course | The onset is typically between late adolescence and early thirties. It more common in females than in males and the disorder tends to be chronic when it onsets in adolescence. |
Aetiology | A first-degree relative with panic disorder and irregular activity of norepinephrine is a risk factor. |
Assessment and treatment | Treatments include cognitive behavioural treatment (1), SSRIs (2) and anti-depressant drugs which restore levels of norepinephrine (3). |
Disorder | AGORAPHOBIA |
Clinical description | Avoidance of certain situations in which people feel like they cannot escape if something (e.g. panic attack) happens there. |
Symptoms | The avoidance of two or more possible situations:
|
Course | It is more common in females than in males. The onset is typically in late adolescence or early adulthood. People often develop the disorder after a panic attack or a panic disorder. |
Aetiology | The family situation often lacks warmth and is high on parental overprotection. There is a strong biological component and it is associated with negative life events. |
Assessment and treatment | Treatment includes systematic desensitization (1), participant modelling (2) and reinforced practice (3). |
Disorder | GENERAL ANXIETY DISORDER |
Clinical description | There is no specific focus of worry but pervasive worry that generalizes across situations and topics. There is excessive worry and an inability to control the worry. It is associated with perfectionistic tendencies and people may require excessive reassurance. |
Symptoms | The following symptoms are included in the diagnosis for 6 months:
|
Course | It is often comorbid with separation anxiety disorder in adolescence and adulthood. It is also comorbid with phobia or depression. |
Aetiology | A malfunction in the neurotransmitter GABA (1), genetics (2), anxious interpretation style (3), self-blame (4) and anxious parents (5) are risk factors. |
Assessment and treatment | The Coping Cat programme can be used as treatment. A child with anxious parents does not benefit from CBT unless the parents are also included. |
Disorder | OBSESSIVE-COMPULSIVE AND RELATED DISORDER |
Clinical description | Obsessive thoughts and compulsive behaviours. The compulsive behaviours are attempts to neutralize the anxiety caused by the obsessive thoughts. |
Course | More females than males have OCD and males have an earlier onset. Hoarding symptoms are more common among older adults but can occur in adolescence. |
Aetiology | A family history of Tourette’s disorder (1), malfunction of the caudate nuclei (2), low levels of serotonin (3) and a dysfunction in the orbital region of the prefrontal cortex (4) are risk factors. |
Assessment and treatment | Treatments include behavioural programmes (1), medical management (2), exposure and response prevention (3) and CBFT (4). |
This bundle contains all the lectures of the course "Childhood: Clinical and School Psychology" given at the University of Amsterdam. The following material is included:
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