Treating Anxiety Disorders in Youth

Contributors:
Matthew J. Paylo, Youngstown State University, Tahani Dari, University of Toledo, Victoria E. Kress, Walden University

Tolerable levels of anxiety and fear are a part of typical development for young people. Yet, fear and anxiety can become problematic and impede some young people’s abilities to function and can even advance to the point of a disorder. Separation anxiety disorder, selective mutism disorder, specific phobia, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder are categorized under anxiety disorders in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013). Anxiety disorders are among the most commonly-diagnosed psychiatric disorders in youth, and the prevalence rates for adolescents are between 15-20% (Beesdo, Dipl-Pysch, & Pine, 2009).

Youth generally exhibit anxiety in three different domains: somatic, cognitive, and behavioral. Youth, and particularly younger children, often report somatic physical experiences of anxiety. Some examples of these physical complaints involve nausea, stomachaches, tics, and in certain instances, palpations or even dizziness. In turn, the physical symptoms affect a young client’s cognitive and behavioral functioning, and vice versa (Kress & Paylo, 2015). Anxiety symptoms also include excessive/irrational feelings of fear and dread in relation to no specific stimulus or a sense of worry and discomfort in reaction to a specific object, situation, or perceived threat (APA, 2013). Anxiety symptoms fluctuate in intensity, duration, and frequency and are often dependent on the environment (APA, 2013).

Resources:
National Institute of Mental Health http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml http://www.nimh.nih.gov/health/statistics/prevalence/any-anxiety-disorder-among-children.shtml

SAMHSA-Substance Abuse and Mental Health Services Administration http://www.samhsa.gov/disorders/mental

Service in United Kingdom http://www.nhs.uk/conditions/anxiety-children/Pages/Introduction.aspx#types

Identification/Assessment Strategies

A comprehensive assessment strategy allows counselors to gather a complete picture of clients’ anxiety experiences and create appropriate counseling plans. Counselors should incorporate parents/caregivers and siblings as sources of information about the young client’s behavior at home. When appropriate, counselors should also solicit collateral reports from teachers, school professionals, and other stakeholders.

During a clinical interview, counselors should be attentive to the age of onset of anxiety symptoms, course of development, and co-occurring disorders (Beesdo et al., 2009). Standardized assessment tools can also be used to gather valuable information.  In addition to assessing anxiety early in counseling, the following measures can also be utilized to assess and evaluate counseling progress over time.

Revised Children’s Manifest Anxiety Scales- Second Edition
The Revised Children’s Manifest Anxiety Scales- Second Edition (RCMAS-2; Reynolds & Richmond, 2008) is a 49-item youth-rated measure used to assess global anxiety, worry, social anxiety, and defensiveness in youth. Questions are posed in a “yes” or “no” format. The measure has a third grade reading level and will require oral administration for younger children. 

Spence Children’s Anxiety Scale
The Spence Children’s Anxiety Scale (Spence, 1998) is a 44-item measure used to assess six domains (i.e., generalized anxiety, panic/agoraphobia, separation anxiety, obsessive-compulsive disorder, and physical injury fears). Youth provide answers on a four-point scale ranging from “never” to “always.” Youth are instructed to read each question and circle the appropriate answer. 

State–Trait Anxiety Inventory for Children
The State–Trait Anxiety Inventory for Children (STAIC; Spielberger, 1983) is a 40-item counselor-rated measure that assesses how a youth feels in a particular moment (i.e., state anxiety) and how he or she feels more generally (i.e., trait anxiety). The measure requires a seventh grade reading level, therefore will need to be administered orally with elementary school-aged children.

Resources:
Information on anxiety disorder assessment tools and rating scales: http://www2.massgeneral.org/schoolpsychiatry/screening_anxiety.asp#spence

National Institute of Health-Articles on measuring and assessing anxiety http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879951/

Intervention Strategies

What follows is an overview of the most evidence-based approaches and interventions used to treat youth anxiety. Approaches rooted in either behavioral therapy or cognitive-behavioral therapy treatment principles are believed to be the most effective in treating youth anxiety.

Behavioral Therapy
Social learning theory is one aspect of behavioral therapy (BT), and it is rooted in the concept that learning transpires through observation and imitating others (Kendall, 2012). One BT intervention that can be used with young clients is social-skills training (SST). The objective of SST is to assist youth in acquiring the skills they need to effectively interact with others. SST is particularly effective with youth experiencing social phobia, but it can be an important aspect of counseling with all youth who have anxiety (Scharfstein & Beidel, 2011).

SST includes developing a young client’s awareness of verbal and nonverbal interactions and how such interactions affect subjective anxiety experiences. Most young people have a limited understanding of how to identify their feelings, identify other peoples’ feelings, or express their own feelings in the context of social interactions. Social skills programs often include (a) identification and expression of emotions; (b) communication of these emotions to others; and (c) an increased ability to self-manage (i.e., being aware of one’s own behaviors in relation to others; Geldard, Geldard, & Yin Foo, 2013).

Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) interventions are effective, evidence-based approaches to apply with children and youth (Freeman et al., 2014; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). The use of CBT in treating youth with avoidance behaviors is highly effective when used in combination with cognitive restructuring and skills training (Seligman & Ollendick, 2011). CBT approaches involve a combination of cognitive restructuring, repeated exposure with reduction of avoidance behaviors, and skills training (Seligman & Ollendick).

Relaxation is a technique used within the CBT (and BT) framework that is critical in addressing youth anxiety. Some examples of specific relaxation practices include deep breathing, deep breathing with imagery, and progressive muscle relaxation. Relaxation training is based on the idea that one cannot be simultaneously physically aroused and relaxed (Kendall, 2012). The main focus of relaxation training is to have clients become aware of their apprehension, worry, and anxiety in the moment and learn how to intentionally reduce the unpleasant sensations. Relaxation skills assist youth in enduring anxiety-related conditions, and should be incorporated into the treatment plans of young people who have anxiety. Counselors are encouraged to integrate mediation, exercise, stretching, painting, listening to music, or any other relaxation activity into counseling to help youth reduce their anxiety.

Another effective CBT intervention for young clients experiencing anxiety is affective education. The aim of affective education is to facilitate a client’s awareness of the relationship between feelings, beliefs, and physical experiences. The end goal of affective education is to have young clients recognize their anxiety patterns and dynamics, and learn the self-awareness and self-regulation skills needed to make positive modifications in their thinking, attitudes, and behaviors (Kendall, 2012).

Exposure therapy is another CBT intervention in which children and adolescents tackle their anxiety-provoking situations via an anxiety hierarchy that they create. An example of a specific exposure therapy program based on CBT treatment principles is Coping Cat (Kendall, Chourdhury, Hudson, & Webb, 2002). The acronym FEAR can be used by young clients to remind themselves of the skills they can use to manage their anxieties (Kendall et al., 2002). The acronym is as follows:

  • Feeling Frightened? Acknowledge your physiological responses to anxiety.
  • Expecting Bad Things to Happen? Identify unhelpful, anxious thoughts.
  • Actions and Attitudes That Can Help: focus on your learned skills to utilize during times of anxiety (e.g., relaxation, problem solving, helpful thoughts).
  • Results and Rewards: evaluate your performance when facing an anxiety-provoking situation.

Psychopharmacotherapy
When considering a referral for a psychiatric evaluation, counselors should consider the youth’s current level of distress and functioning, the severity of symptoms, and the young client’s mental health history (Kress & Paylo, 2015). Medication, specifically Selective Serotonin Reuptake Inhibitor (SSRIs)—combined with behavioral or cognitive behavioral therapy—can be helpful in addressing youth anxiety (Ginsburg et al., 2011). Benzodiazepines (e.g., Ativan, Valium, Klonopin) have not been demonstrated as generally effective in treating youth anxiety disorders, and their use warrants more research and exploration (Strawn, Sakolsky, & Rynn, 2012).

Medication compliance should be integrated into young clients’ treatment plans, and counselors are encouraged to collaborate with medical professionals, clients, and their families to ensure medications are being taken as prescribed.

Resources:
Agency for Healthcare Research and Quality (AHRQ) https://www.guideline.gov/summaries/archive/withdrawn/1018#1018

Anxiety and Depression Association of America http://www.adaa.org/finding-help/treatment

Information for caregivers on anxiety: http://childanxiety.net/

http://childanxiety.org/wps/parent-resources/tips-for-parents/

National Center for Complementary and Integrative Health https://nccih.nih.gov/health/stress/relaxation.htm

Relaxation Techniques: http://raisingchildren.net.au/articles/breathing_for_relaxation.html

REFERENCES

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Beesdo, K. B., Dipl-Psych,  S. K., & Pine, D. S. (2009). Anxiety and anxiety disorder in children and adolescents: Developmental issues and implications for DSM-V. Psychiatric Clinics of North America, 32, 483-534. doi:10.1016/j.psc.2009.06.002

Freeman, J., Garcia, A., Frank, H., Benito, K., Conelea, C., Walther, M., & Edmunds, J. (2014). Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 43(3), 7-26. doi:10.1080/15374416.2013.804386.

Ginsburg, G. S., Kendall, P. C., Sakolsky, D., Compton, S. N., Piacentini, J., Albano, A. M., …March, J. (2011). Remission after acute treatment in children and adolescents with anxiety disorders: Findings from CAMS. Journal of Consulting and Clinical Psychology, 79(6), 806-813. doi:10.1037/a0025933

Geldard, K., Geldard, D., & Yin Foo, R. (2013). Counselling children: A practical introduction (4th ed.). Thousand Oaks, CA: Sage.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. doi:10.1007/s10608-012-9476-1

Kendall, P. C. (2012). Anxiety disorders in youth. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive- behavioral procedures (4th ed., pp. 143-189). New York, NY: Guilford.

Kendall, P. C., Choudhury, M., Hudson, J., & Webb, A. (2002). The CAT project manual. Ardmore, PA: Workbook Publishing.

Kress, V. E., & Paylo, M. J. (2015.) Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment. Columbus, OH: Pearson.

Reynolds, C. R., & Richmond, B. O. (2008). Revised children’s manifest anxiety scales – second edition. Torrance, CA: Western Psychological Services.

Scharfstein, L., & Beidel, D. C. (2011). Behavioral and cognitive-behavioral treatments for youth with social phobia. Journal of Experimental Psychopathology, 2, 615-628. doi:10.5127/jep.014011

Seligman, L. D., & Ollendick, T. H. (2011). Cognitive behavioral therapy for anxiety disorders in youth. Child & Adolescents Psychiatric Clinic, 20(2), 217-238. doi:10.1016/j.chc.2011.01.003

Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545-566. Retrieved from http://www.scaswebsite.com/docs/spence-1998-scas.pdf

Spielberger, C. D. (1983). Manual for the State-Trait Inventory for Children. Palo Alto, CA: Consulting Psychologists Press.

Strawn, J. R., Sakolsky, D. J., & Rynn, M. A. (2012). Psychopharmacologic treatment of children and adolescents with anxiety disorders. Child and Adolescent Psychiatric Clinics of North America, 21(3), 527-539. doi:10.1016/j.chc.2012.05.003

Published: December 2015
Updated: August 2016

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