What are the concepts anxiety, stress, and phobia?

There is a difference between anxiety and fear. Anxiety is an emotion that is focused on the future. This emotion is characterized by the feeling that someone has no control over possible negative events. The events also seem to be unpredictable for the person in question. If someone is confronted with potentially dangerous events, there is immediately a lot of attention for the dreaded (or for the emotions that accompany it).

Stress is a response to an existing threat. It is characterized by an alarm response. stress and fear are considered a complex pattern of three types of responses to perceived threat:

• Behavioural reactions, such as running away, stuttering and closing eyes.
• Cognitive reactions, such as thoughts of fear and anxiety and mental images of physical injury.
• Physical reactions, such as changes in heart rate, sweating, contracting muscles and a feeling of nausea.

Anxiety is a cognitive component of stress and is difficult to control. Worries are thoughts about possible negative consequences that are difficult to control.

It is difficult for clinicians to determine whether the anxiety of a child or adolescent is normal and temporary, or atypical and persistent. Anxiety is part of normal development, as a result of which children develop certain competencies and become more autonomous, for example. For example, children learn how to cope with the dark, while adolescents learn how to cope with dating fears.

Age differences, gender differences and cultural differences

Both the number and the intensity of fears decrease with age. Concern becomes prominent around the age of 7 and becomes more complex and varied as development progresses. Certain fears appear to be more common at certain ages, such as the fear of strangers between 6 and 9 months after birth and social anxiety and fear of failure in adolescence. Changes in the content of fears and worries are probably a reflection of cognitive, social and emotional development.

Anxiety disorders are more common among girls than among boys. This gender difference also becomes larger with older children. It is suggested that the intensity of anxiety in girls is also higher. However, research findings regarding gender differences should be interpreted with caution because they may be (partly) the result of gender-specific expectations about showing anxiety.

Cross-cultural research suggests that there are similarities between cultures. The most common fears are the same in different countries and cultures.

Classification

The DSM anxiety disorders category includes anxiety disorder, specific phobias, social phobia, panic disorder, generalized anxiety disorder and the likes. A child or adolescent can be diagnosed with one or more anxiety-related disorders at the same time too.

Epidemiology

Anxiety disorders are among the most common disorders of children and adolescents. Prevalence estimates from different studies vary considerably. Young children often meet the diagnostic criteria of multiple anxiety disorders. In addition, this disorder persists in a significant proportion of children throughout life. These children often also develop other problems. It is unclear whether there are differences between ethnic groups in the prevalence of anxiety disorders. However, there may be differences in the prevalence of specific anxiety disorders.

What are 'specific phobias'?

Description

A phobia is an excessive anxiety that cannot be controlled and it leads to avoidance and interferes with functioning. A specific phobia is a persistent, unusual and excessive fear of a specific object or situation. The diagnostic criteria are as follows:

• Almost every time the person is exposed to the phobic stimulus, he or she exhibits an immediate fear response.
• The person realizes that the fear is unreasonable or excessive.
• The person avoids the anxiety situation or experiences anxiety or stress when exposed.
• The fear has been present for a period of at least six months.

In addition, the fear causes a lot of stress and or or significantly interferes with daily life, academic functioning or social relationships.

With a specific phobia, the person often has thoughts about disastrous events that could result from exposure to the phobic stimulus. There may also be physical reactions to this stimulus, such as nausea or an accelerated heartbeat.

Epidemiology

Specific phobias are one of the most common anxiety disorders among children and adolescents. In community samples, the prevalence varies between 3% and 4%. Specific phobias are more common in girls than in boys. Children with a specific phobia usually have multiple phobias and often meet the criteria of other disorders, such as mood disorders, depression and externalizing disorders.

Development process

Specific phobias often arise in early to mid-childhood and can be persistent. However, research suggests that improvement may also occur, with or without treatment.

What is Social Anxiety Disorder (Social Phobia)?

Description

The diagnostic criteria for social anxiety disorder (social phobia) are the same as for specific phobias. However, this concerns fear of social or assessment situations. The most important characteristic of a social phobia is therefore a persistent fear of doing something wrong or shameful in a social or assessment situation. For example, they are afraid of social activities such as talking or presenting. They are afraid to start or maintain conversations and to talk to authoritative figures. In addition, they try to avoid situations involving social interactions or assessments. This increases the chance of little or bad friendships and feelings of loneliness. Children with social phobia have a negative self-image and are inclined to incorrectly interpret other people's reactions as critical or disapproving. They also often experience somatic complaints such as nausea or tremors.

Children with a social phobia are expected to be able to have appropriate social relationships with people they are familiar with. In addition, they are expected to experience social anxiety in the presence of both adults and peers.

Selective mutism

Children with selective mutism often do not speak in specific social situations. The average age at which this disorder develops is between 2.5 and 4 years but can go unnoticed until the child goes to school. Children with selective mutism are often described as shy, withdrawn and affectionate on an almost clingy level. Some also exhibit language problems and show stubborn, disobedient and or or oppositional behaviour. Selective mutism is probably caused by a complex interaction between genetic and environmental factors. Research suggests that it can be considered an extreme form of social anxiety, because possibly 90% to 100% of children with selective mutism also meet the diagnostic criteria of a social phobia.

Epidemiology

Social phobia occurs in approximately 1-2% of children and in approximately 3-4% of adolescents. A social phobia often develops in mid to late adolescence. A social phobia can go unnoticed because children with a social phobia minimize their problems by behaving in a desirable way. Often children with social phobia also meet the criteria for other disorders.

Development process

Fears of social and assessment situations increase with age and are related to changes in socio-cognitive development. Self-awareness is an essential part of a social phobia. The ability to see oneself as a social object and to experience feelings of shame arises around the age of 4 to 5. Making a representation of the perspective of others and experiencing concerns about a possible negative evaluation arises around the age of 8. In late childhood or early adolescence, all cognitive requirements are present to develop social phobia. In addition, from this period onwards, young people are expected to perform tasks with a social-evaluative component, such as speaking out loud in class.

Separation fear

Description

With separation anxiety there is an excessive fear of being separated from an important attachment figure and or or from home. The diagnostic criteria state that there must be at least 4 weeks of three or more symptoms before the age of 18. In addition, there must be a significant limitation for social, school or other related functioning. Young children with separation anxiety are affectionate, may experience nightmares and may have somatic symptoms including nausea. Older children mainly have somatic complaints, think about possible illnesses or accidents that may happen to themselves or an important attachment figure if they were to be separated or become apathetic and depressed. Some children may threaten to harm themselves. This is usually a means to avoid separation.

Epidemiology

Prevalence estimates of separation anxiety in community samples range from 3-12% of young people. Separation anxiety is more common among children than among adolescents. Children and adolescents with separation anxiety often also meet the criteria of other disorders, such as a generalized anxiety disorder. It is unclear whether there are gender and ethnic differences in the prevalence of separation anxiety.

Development process

Fear of separation from a primary caregiver is part of the normal development process of young children. The absence of stress during separation may even indicate an unsafe bond. Separation anxiety is only considered problematic if it is persistent or excessive. In children with separation anxiety disorder, the symptoms often develop from mild to more severe. Most children recover from the disorder. In other children the symptoms persist, and another disorder develops and progresses into another disorder, such as depression.

School refusal

Description

School refusal occurs when children refuse to go to school due to excessive anxiety. School refusal is not a disorder in the DSM but is a symptom of a few disorders such as separation anxiety disorder. School refusal can have various causes. Some experience separation anxiety, but other children are afraid of a specific aspect of the school experience, such as public speaking. They can be diagnosed with a specific or social phobia. Children who refuse to go to school often also suffer from depression. School refusal often arises as a result of stressful changes in life, for example after a death, a change of schools or moving to a new place.

School refusal can also be classified by means of a functional analysis instead of on the basis of symptoms, so on the basis of its function. Some young people refuse to go to school or stay at school to avoid school-related stimuli that generate fear. Another function is to get attention from others, such as the parents. Finally, some children are empowered for not going to school because, for example, they are allowed to watch television. A treatment plan can be drawn up based on a functional analysis.

A distinction must be made between school refusal and truancy. Children that decide to skip school are generally not afraid to go to school and simply skip school in secrecy occasionally Skipping children often exhibit poor school performance and behavioural problems, but these are unrelated to school refusal.

Epidemiology and development process

School refusal occurs in 1-2% of the general population and in 5% of the clinical population. It is just as common among girls as it is among boys. School refusal occurs at all ages but is most common at important moments of transition. School refusal treatment is most successful at an early stage and treatment must be adapted to the specific function of school refusal.

What is generalized anxiety disorder?

Description

A generalized anxiety disorder is characterized by excessive anxiety and concern about various events or activities. The child finds it difficult to control these fears or worries. The anxiety and worries are not limited to a specific type of situation. The diagnostic criteria state that at least 6 months on most days there must be one or more of the following symptoms:

• Restlessness, nervousness
• Being tired quickly
• Concentration problems
• Irritability
• Tense muscles
• Sleep problems

These symptoms must interfere with the child's functioning. The DSM recognizes development differences. For example, a child only needs to show one of the six symptoms mentioned above, while adults need three symptoms to get the diagnosis.

Children with generalized anxiety disorder are concerned about their ability and performance in various areas. They are often perfectionistic and can place unreasonably high demands on themselves. They can also be concerned about financial matters and or or natural disasters. They constantly seek approval and reassurance and display nervous traits, such as nail biting. Somatic complaints also occur regularly.

Epidemiology

Prevalence estimates of a generalized anxiety disorder range from 2-14%. It is probably the most common anxiety disorder in adolescents. It is unclear whether there are sex differences in the prevalence of the disorder. The most common age at which a generalized anxiety disorder develops is around 10 years of age. The number and intensity of symptoms increases with age. Children with general anxiety disorder often have other disorders, such as depression, phobias and separation anxiety.

It is possible that the disorder will be over-diagnosed. Some doubt whether it is a separate disorder or part of a larger or more specific picture. It may be a dimension of a general vulnerability to fear or emotional reactivity.

Development process

A generalized anxiety disorder does not seem to be temporary. Symptoms can be persistent for several years. With regard to comorbidity, it appears that young children with the disorder often have separation anxiety disorder at the same time, while adolescents often deal with social phobia or depression alongside it. This suggests that there is a developmental difference in the way generalized anxiety is experienced. However, because separation anxiety is more common among young children and social anxiety and depression among adolescents, it is possible that these findings are consistent with the above question of whether generalized anxiety disorder is a separate disorder.

What is a Panic disorder?

Description

A distinction is made between panic attacks and a panic disorder . A panic attack is a short period of intense fear or panic that suddenly starts and reaches a peak within approximately ten minutes. The diagnostic criteria state that during a panic attack there must be at least 4 of the following symptoms:

1. 1. palpitations or accelerated heartbeat,
   2. sweating,
   3. shaking,
   4. shortness of breath,
   5. feeling of suffocation,
   6. chest pain,
   7. nausea or abdominal pain,
   8. dizziness, lightheaded or fainting,
   9. feeling cold or hot flush
   10. feeling numb
   11. derealization (the feeling that environment is not real) or depersonalization (the feeling of being outside reality
   12. feeling of losing control,
   13. fear of dying.

A distinction is made between panic attacks based on the presence or absence of triggers. unexpected panic attack takes place spontaneously, without a clear situational reason. An expected panic attack can be situational-related panic attacks. These panic attacks almost always occur with (the anticipation of) exposure to a dreaded object or situation. However, it may also be that the panic attack does not always occur after exposure to a situational trigger, or only after (and not during) the exposure to it. Panic attacks themselves are not in the DSM but can take place in the context of a disorder. A panic attack can occur in agoraphobia: the fear of being in a difficult or embarrassing situation from which it is difficult to escape. The child tries to avoid certain circumstances in which an uncontrollable or embarrassing panic attack can occur or in which no help is available.

In a panic disorder, recurring unexpected panic attacks occur. The diagnostic criteria state that at least one of the panic attacks has been followed for at least a month by one of the following:

• Persistent concerns about having panic attacks or concerns about the implications of the panic attack.
• A significant behavioural change that is related to the panic attacks.

Only recently attention has been paid to the existence of panic in children and adolescents. Its existence was controversial due to two issues:

• It was doubted whether young people experience the cognitive components of panic, such as the fear of losing control.
• It is difficult to determine whether panic feelings of children actually arise without cause.

Epidemiology

Panic attacks and disorders can occur in adolescents and, to a lesser extent, in prepubescent children. It is rarely diagnosed before mid or late adolescence. Panic attacks are just as common among girls as they are boys. However, a panic disorder is more common among girls. There is little information regarding ethnic differences in the prevalence of panic attacks and disorders.

Development pattern

Adolescents who have panic attacks rarely seek help. They often have family members who also have (had) panic attacks, a panic disorder or other anxiety symptoms. A large proportion of young people who suffer from panic attacks and or or panic disorder are also diagnosed with other disorders, such as other anxiety disorders and depression. Possibly separation anxiety is a precursor to a panic disorder.

What is Post-traumatic stress disorder (PTSD)?

A trauma is defined as an unusual experience, which in almost everyone would lead to stress. In the DSM-IV, PTSD belongs to the Trauma and Stressor-related disorders group. The diagnostic criteria for a post-traumatic stress disorder (PTSD) state that the child must be exposed to a traumatic event, to which the child has responded extremely anxiously. In addition, there must be at least one month of the PTSD triad of symptoms:

• Reliving the traumatic event through, for example, dreams and memories.
• Avoiding trauma-related stimuli and numb general responsiveness.
• Negative changes in cognition and mood
• Persistent symptoms of increased alertness, such as sleeping and concentration problems.

There are indications that young children are under-diagnosed with the current criteria and that the criteria must be adjusted for them. For example, it has been suggested that very young children may also suffer from PTSD if they did not show intense anxiety at the time of the traumatic event. Moreover, in young children there may be differences in the number and type of symptoms of relapse, avoidance and alertness. For this reason, the DSM-IV has been given a parallel set of criteria for children 6 years of age or younger. Fewer symptoms are needed for a diagnosis, and examples of manifestations of symptoms in this age group have been added.

The reactions of children with PTSD vary considerably. They may have recurring thoughts about the event and specific trauma-related fears. They also become affectionate and there are depressive symptoms. Some children feel guilty because the child has survived the trauma, while others have died, this is called survivors guilt.

Epidemiology

A quarter of the children and adolescents have had a serious traumatic experience before or at the age of 16. One third to half of the children who have experienced a traumatic event develop PTSD. Most studies show that PTSD is more common among girls than among boys. Development differences may exist in the way PTSD is expressed. The PTSD cluster of symptoms (re-experience, avoidance, alertness) occurs in young people from different cultures. The most common symptom is probably reliving the trauma.

The duration and severity of PTSD symptoms depend on a number of factors, including the nature of the traumatic event. Stressors can be distinguished into acute, non-abusive stressors (non-abusive traumatic events that only occurred once, for instance, a car accident) and chronic or abusive stressors (ongoing stressors such as war or sexual abuse). Some symptoms vary depending on the type of trauma. The degree of exposure to the traumatic event also plays a major role. Finally, individual differences prior to a traumatic event affect the response to a traumatic event.

Development process

In general, PTSD symptoms decrease over time, but a large proportion of children with PTSD continue to have symptoms. The way children initially try to deal with the trauma can influence the development of the symptoms. Children with negative coping strategies have a bigger chance of persistent symptoms. Moreover, the reactions of children and adolescents are related to the reactions of their parents and others from the environment. If parents themselves suffer from PTSD or are unable to create a supportive and open atmosphere, the symptoms are often more severe.

What is Obsessive Compulsive Disorder (OCD)?

Description

OCD falls under the obsessive compulsive and related disorders group.

Obsessions are unwanted, repeated and penetrating thoughts. Common obsessions are concerns regarding contamination (fear of germs) or symmetry, order and precision. Compulsions are repetitive, stereotypical behaviours that someone thinks should be performed to reduce anxiety or prevent a dreaded event. Common compulsions are washing things and repeating actions (for example, repeatedly turning the light switch on and off). An obsessive-compulsive disorder (OCD) includes obsessive thoughts and or or compulsions. The diagnostic criteria state that the person is aware that obsessive thoughts and compulsive behaviours are unreasonable. However, children do not have to meet this requirement to be diagnosed with OCD. Another criterion for diagnosing OCD is that obsessions and compulsions take a lot of time and interfere with daily life, academic functioning and social relationships. In children, compulsions are much more common than obsessions, while both are equally prevalent in adults. OCD is often only recognized in children if the symptoms are very serious. Sorting out the crayons in the right colours doesn’t seem very odd until the kid started to obsessively stress over doing the action or not having performed it.

Epidemiology

In the general population, OCD occurs in approximately 1% of adolescents. The disorder is more common in boys at a younger age, but there is no longer a gender difference in adolescence. A study has shown that the average age at which OCD develops is 9 years for boys and 11 years for girls. Most children and adolescents with OCD also meet the criteria for at least one other disorder, such as an anxiety disorder, ADHD, depression, and behavioural disorders. OCD is also regularly associated with Tourette's syndrome (a chronic disorder with a genetic and neuroanatomical origin, which is characterized by motor and vocal tics) or other tic disorders. A tic is a fast, sudden and recurring stereotype motor movement or vocalisation, such as snapping the fingers. It is unclear whether children and adolescents with tics are a separate subtype of OCD with regard to symptoms and the response to treatment.

Development process and prognosis

Behaviour with obsessive-compulsive characteristics occurs at different stages of normal development. Mild compulsions, such as stepping over the cracks in sidewalk tiles, are normal for children between eight and ten years old. There is only cause for concern when the behaviours control the child's life and interfere with normal functioning. In addition, the specific content of OCD rituals often has a different content than common development rituals and OCD rituals often have a later starting point. It is unclear whether developmental rituals are an early manifestation of OCD.

Regarding the development course of OCD, there is heterogeneity. The disorder follows a development in which symptoms arise and disappear over time. Usually there are multiple obsessions and compulsions at one time. Over the course of time, the symptoms often change in content and intensity. The disorder is probably chronic. Although treatment improves around three quarters of young people, the problems often persist, though often in a decreased frequency and intensity.

Biological causes of anxiety disorders

There is evidence for a biological predisposition to anxiety disorders. Several studies have shown that a genetic component contributes to the development of anxiety disorders. Estimates of the degree of heredity vary, but it is suggested that there is moderate heredity. Heredity can depend on how the anxiety is expressed and is possibly greatest for a generalized anxiety disorder and an obsessive-compulsive disorder. In addition, research shows that heredity is possibly the greatest for young children. As children grow older, the relative contribution of genetic influences decreases, and the influence of the shared family environment increases.

It is also possible that children inherit a general tendency, such as emotional reactivity to stimuli, instead of a specific anxiety disorder. This general tendency can be a risk factor for the development of both anxiety and depression.

Genetic influences can be expressed by differences in specific brain circuits and neurotransmitter systems. Neurotransmitters, such as serotonin, probably play a role in the development of anxiety and panic. GABA is a neurotransmitter that inhibits anxiety and panic. Anxious people have relatively little GABA. Finally, research has suggested that the limbic system (especially the amygdala) play a role in anxiety.

Biological causes of OCD

Many researchers believe in a biological predisposition for OCD. Studies have shown that there is heredity. OCD is associated with neurobiological abnormalities in the basal ganglia. PANDAS is a variation on OCS . In PANDAS, OCD symptoms and tics suddenly develop or worsen after an infection. This subtype OCS is probably the result of an autoimmune system response to the infection: antibodies are formed against the streptococci that cause the cells of the basal ganglia to be inflamed.

Temperament

The general vulnerability to anxiety is probably also related to the temperament of a child. The temperament refers to biologically based, probably inherited, individual differences in emotionality, attention and behavioural style. Behavioural inhibition is one of the components of temperament. Retired children (children with a high level of behavioural inhibition) are very vigilant, especially in new or unknown situations. Behavioural inhibition can increase the risk of an anxiety disorder in the context of certain environmental influences, such as certain parenting styles. Gray introduced the gedragsinhibitiesysteem ( behavioural inhibition system, BIS) . The BIS system is related to emotions of fear and fear and causes a tendency not to act in new or scary situations.

Clark and Watson introduced the temperament dimension of negative affectivity (NA) : a general and persistent negative mood. The development of both anxiety and depression are characterized by a high level of NA. NA can also be accompanied by a low level of the temperament factor effortful control (EC): the capacity for self-regulation. Anxious children with a high level of NA pay more attention to negative stimuli and respond more strongly to them, which means they need more EC. The combination of a high level of NA and a low level of EC can therefore contribute to the development and maintenance of anxiety.

What are the psychosocial causes of anxiety disorders?

Children with a general vulnerability to anxiety can be exposed to experiences that influence the risk of an anxiety disorder. One way to conceptualize psychosocial influences is Rachman's three-path theory. Rachman stated that there are three ways in which fears and phobias are learned:

• Classical conditioning: anxiety arises in response to exposure to a traumatic or threatening event and avoidance is empowered by anxiety reduction.
• Modelling: the child learns to respond anxiously to an object or situation by seeing that others react anxiously to it. For example, if parents are anxious, they model this behaviour.
• Transfer of information: for example, parents can tell the child that a certain situation is threatening or something to be scared of.

Parents can also influence the development of anxiety through parenting styles and parenting practices. It has been suggested that the psychosocial influences on the development of anxiety are related to the perception of control and the development of an avoiding coping style. A high-quality birth is conducive to the emotion regulation of children.

Parents of anxious children are often described as overprotective or intrusive. Overprotective or intrusive parents limit the child's activities and instruct the child on how the child should think and how he or she should feel. Such parenting behaviour influences the degree to which the child feels that they have control and the development of adaptive problem-solving styles. This effect can also work in reverse: an anxious child can evoke an overprotective parenting style. An unsafe attachment style is also a risk factor for the development of anxiety disorders. The attachment relationship contributes, among other things, to the development of emotion regulation.

However, families can also offer protection against the development of anxiety disorders. For example, family support offers protection when children are exposed to a traumatic event.

Relations with peers can also influence the development of anxiety in different ways. For example, withdrawn children can be excluded or bullied by peers, which is associated with internalizing problems. Having close friendships can offer protection against the negative effects of rejection by the larger peer group. However, a close friendship can also be a risk factor if the close friends themselves are also withdrawn and less socially skilled. In that case, friendship can maintain the young person's anxious behaviour.

Assessment of anxiety disorders

The assessment of anxiety disorders must take into account the child's level of development and cultural background. In addition, an assessment must be made of the child's environment, such as the patterns of family interactions. The assessment of anxiety disorders is often done on the basis of the three-part model of anxiety. We look at (1) behavioural, (2) cognitive and (3) physical response systems. There are different assessment methods.

Interviews and self-reporting

It is possible to conduct interviews. An example of a semi-structured diagnostic interview is the Anxiety Disorders Interview Schedule for Children (ADIS-C or P). This interview is based on the classifications of the DSM and is conducted by both the parents and the child. However, the most commonly used method for assessing anxiety in children is self-reporting. Self-reporting provides insight into the behavioural, cognitive and physiological aspects of anxiety. It is important to assess symptoms from the child's point of view, as it can be difficult for adults to provide a reliable picture of them. However, young children often find it difficult to put their own emotions into words, so it might not work as well all the time.

There are different types of self-reports. Some instruments relate to anxiety in a specific situation, while there are also instruments that measure general anxiety. In addition, there are self-reporting tools that are specifically aimed at the cognitive component of anxiety or that are aimed at identifying specific anxiety disorders.

Observations

Direct observations are mainly used to assess the overt behavioural aspects of anxiety but can also be used to make an assessment of the environmental factors that can influence anxiety. In a behavioural avoidance test, the child is asked to perform a number of tasks that are related to the dreaded object or situation. It is also possible to observe a child in his or her natural environment, where the child experiences fear. Finally, it is possible to use self-monitoring, whereby the child keeps a systematic record of his or her own behaviour.

Physiological measurements

The physical aspects of anxiety are often measured by self-reporting but can also be directly assessed by measuring parameters such as the heartbeat and blood pressure. For practical reasons, however, this is rarely done in practice.

What are the psychological treatments for anxiety disorders?

Research shows that children with anxiety disorders benefit from cognitive behavioural therapy. There are various cognitive behavioural techniques:

• Exposure to frightening situations . For example, a child suffering from a phobia for spiders can be exposed step by step to a spider.
• Relaxation training. Individuals learn to become aware of their physical and muscle responses to anxiety. They learn skills to influence these responses. After a lot of practice, the person can remain relaxed if he or she is confronted with a dreaded object or situation.
• Systematic desensitization. Exposure and relaxation training are combined. A list is made of frightening situations, ranging from the least scary to the scariest. The person is asked to form mental images of these situations and to relax at the same time. The least scary situation is started and then the following situations are continued until the scariest situation is reached. This is done until a mental picture can be made of the scariest situation in a calm manner. In vivo desensitization uses the real object or situation instead of visualization.
• Modelling. The child observes someone who adaptively deals with the dreaded situation. With participatory modelling, the child initially observes, but then the child participates with the model in approaching the dreaded object.
• Contingency management. This technique is based on operant conditioning and changes the consequences of the fearful or avoidant behaviour. Only after exposure is there confirmation. Contingency management is often combined with modelling, relaxation training and desensitization.

There is much evidence for the effectiveness of cognitive behavioural therapy for anxiety disorders in children and adolescents. Cognitive behavioural therapy has a number of goals:

• Teach the child to recognize the signs of anxiety and alertness.
• Teach the child to identify the cognitive processes associated with anxiety and alertness.
• Teaching the child to use strategies and skills to deal with anxiety.

An example is the FEAR program devised by Kendall. This program aims to teach children four skills:

1. 1. recognizing physical symptoms of anxiety,
   2. recognizing anxiety cognitions,
   3. developing coping strategies
   4. thinking about positive consequences.

The FRIENDS program is an adapted form of the FEAR program, in which the family plays a greater role. The child and parents are treated in small family groups. In addition to teaching the children skills, the parents are taught to communicate better with the child, to deal with the child's fear in a good way and to solve problems effectively. This program appears to be effective even in the longer term.

Pharmacological treatment

Various psychotropic drugs have been suggested for the treatment of anxiety disorders. The evidence is greatest for the effectiveness of SSRIs (selective serotonin reuptake inhibitors) in the treatment of generalized anxiety, separation anxiety and social anxiety. SSRIs reduce anxiety, but cognitive behavioural therapy remains necessary for the acquisition of coping skills. In addition, it is not clear what the long-term risks of SSRIs are. SSRIs have mild side effects, but some researchers state that they increase the risk of depression and suicidal tendencies, so a warning has been issued about the risks of SSRIs from the FDA.

The treatment of obsessive-compulsive disorder

Obsessive compulsive disorder (OCD) can best be treated with cognitive behavioural therapy in the first place. The use of medication (SSRIs) is a second option.

Through cognitive behavioural therapy the child learns what OCD entails. In addition, the child learns skills to change cognitions and to resist obsessions and compulsions. One can also make use of contingency management and self-reinforcement. However, the most important aspect of cognitive behavioural therapy is treating the exposure prevention response. In this treatment,  the child is gradually exposed to the situation that causes fear. At the same time, the compulsive ritual is prevented by helping the child to resist the urge to compulsion.

With imaginative exposure, the child is given a detailed description of the feared situation to induce fear. This takes a few minutes, during which he or she is not allowed to have any thoughts or behaviour to avoid the fear. This exposure is repeated until the anxiety is considerably reduced. As a supplement to or alternative to imaginative exposure, the child may be exposed to actual frightening situations, however it depends on the phobia how ethical and possible this is.

Prevention of anxiety disorders

It is important to prevent anxiety disorders, because they increase the risk of other disorders (such as depression). The content of prevention programs is very similar to the cognitive behavioural therapy described above. Indicated prevention programs target young people who have mild symptoms but do not yet meet the criteria for anxiety disorders from the DSM. The FRIENDS program appears to be effective (in the longer term) in the prevention of anxiety disorders in 7 to 14-year-old children with mild symptoms of anxiety disorder. A selected prevention program is aimed at children who are at high risk of developing an anxiety disorder, for example because they have parents who have reclusive behaviour. It is suggested that prevention has more effect at a younger age than a later one.