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Child Anxiety Disorders

Interview w/ Ron Rapee, Clinical Psychologist

Ron Rapee is a Clinical Psychologist (B.Psych, M.Psych, PhD) who specializes in Anxiety Disorders. He works with children who develop an Anxiety Disorder. He is currently working at the Child and Adolescent Anxiety Clinic at Macquarie University.

Q. What are the statistics for childhood anxiety in Australia?

Rapee: There is no data on the prevalence of anxiety disorders in children in Australia. However, there is data from New Zealand and the USA and there is no reason to believe that Australia should be dramatically different. Overall, anxiety disorders are as common, or more so, as so-called oppositional and conduct disorders combined. In other words, as a group, anxiety disorders are the most common problems in children and adolescents. In fact, one recent study of 13-18 year old Dutch adolescents, found that the two most common disorders of all were simple phobia and social phobia, being diagnosed in 12% and 9% respectively. In that study, a diagnosis of any anxiety disorder was found in 24% of the sample, while disruptive disorders were found in only 8%, mood disorders in 7%, and substance abuse in 4%. Despite the fact that suicide and drug abuse grab all the publicity, anxiety is far more common.

Q. At what age can a child develop an anxiety disorder?

Rapee: There is no particular age, but anxiety and fears are often obvious from a very early time. Obsessive Compulsive Disorder (OCD) is seen in children as young as 5. Specific phobias, such as phobias of spiders, the dark, dogs, etc. are common in young children anywhere from 7-9 years.

Social fears and shyness can often show signs from very early ages - 5, 6, or 7 and up, even though this problem then often becomes more common and more intense in the teenage years. Separation fears are more common at younger ages, and become obvious whenever separation from a caregiver is begun (say, with the beginning of school, or even day care). The main disorder, which is not typically seen in young children, is panic disorder. Panic attacks are very rare in young children, become a little more seen in adolescents (although still not common) and are most likely to begin in the 20's.

One of the main issues, however, is to distinguish between what we might call an actual "anxiety disorder" from a general tendency to be anxious. Researchers have found that it is possible to identify children as early as 18 months who show anxious behaviors that increase the chances of developing later anxiety disorders. These children who are high on what is called an "anxious temperament" show crying, clinging, and avoidance in the face of new, or unusual events. They are shy with strangers (more than the average) and are slow to warm up in groups.

So, in a sense, we can say that anxiety is a general personality style and a life-long pattern that can be seen to some extent very early. At Macquarie University, we are just beginning a large research project to examine the effectiveness of teaching parents of high-anxious temperament 4-year old children strategies to help their child control his or her anxiety. In the next one-to-two years we can begin to report on how this has gone.

Q. How can a parent tell if their child has an anxiety disorder?

Rapee: Most parents will know if their child has a problem with anxiety. Anxious children fear particular things (e.g. other people, separation) and this fear is more than is seen in other kids of their age. Anxious children will talk about their fears, if asked. So, as parents, we need to ask and listen. They will describe worries just like adults do and will avoid situations and activities. The bottom line is to ask yourself whether the degree of anxiety that your child shows is interfering with his or her life - is it reducing opportunities, is it reducing academic work, is it interfering with friendships or social activities? If so, then it would be good to do something about it. Whether it is technically called an "anxiety disorder" or not, is irrelevant.

Q. What are the factors that contribute to development of an anxiety disorder?

Rapee: We don't know all the answers to this yet and there are obviously many factors that go to make an individual that we may never fully understand. But research is beginning to uncover some factors that seem to increase the chances of developing an anxiety disorder.

First, there is a particular personality or temperament. This is probably largely a genetically-based component. Some people are simply born more sensitive, caring, and emotional than others. This obviously has some good aspects to it, but the down side is that these people are at increased risk for later problems with anxiety and depression.

Anxious children often have at least one parent who is also anxious. Parenting is a big factor in a child's life and it is very likely that this is also involved in some ways. Our own research is beginning to show that parents of anxious children are more involved in their child's life and are more controlling and protective. This stems out of a basic love for their child and a response to their anxious child's cries for help. But when it happens, it can help to reinforce and increase the anxiety by giving the child the message that the world really is a dangerous place and that she or he is not competent to handle it. Children also learn a great deal from watching their parents. So, if a parent of an already anxious temperament child, acts in an anxious way them self, then the child will learn from this and it might exaggerate their natural anxious style. Friends and relationships at school and elsewhere could possibly also maintain and increase anxiety in a child in much the same way as overprotective parenting.

Finally, there are also many individual experiences that can trigger anxiety disorders. These include life stresses, traumatic experiences, and specific learning experiences. For example, being bitten by a dog may produce a fear of dogs in someone who is already vulnerable to an anxiety disorder due to the factors we discussed above.

Q. What is the difference between an anxiety disorder and separation anxiety?

Rapee: Anxiety disorder is a broad term that simply refers to any of several different disorders. Separation anxiety disorder is one of these. The most common anxiety disorders in children and adolescents are simple phobias (e.g. fears of the dark, dogs, etc.), separation anxiety disorder, social phobia, and generalized anxiety disorder. Obsessive compulsive disorder is less common but is certainly seen in a sizeable number. Post-traumatic stress disorder, of course, is seen in specific groups - those who have been through some type of trauma, such as sexual abuse, car accidents, assaults, etc. Panic disorder is very rarely found below the age of 16.

Anxiety disorders are not some type of "craziness" or "disease". Aspects or features of all anxiety disorders are found in all people. So anxiety disorders differ from non-disordered anxiety only in degree. Therefore, how we decide if someone has an anxiety disorder is a matter of where we draw the cutoff - and this is largely arbitrary.

All children will go through stages of very normal fears and anxieties. At around 1-2 years, all children will show strong fears of strangers and separation. A little later, fears of the dark will begin. Therefore, whether a child has "normal" separation fears or separation anxiety disorder, is a largely arbitrary decision and one which is probably not that important. The important decision is simply whether a child's degree of fear is so much that it seems to interfere with his or her life. In this case, it may be worth getting help to reduce this fear, regardless of whether one would technically call it a disorder.

Q. What are the treatments currently used for anxious children?

Treatment for anxiety in children follows very similar lines to that in adults, including both medication and psychotherapy. In children, the main treatments that have been properly tested experimentally and shown to produce excellent results are the teaching of practical, cognitive/behavioral skills. At Macquarie University, we run a 9-session group program that includes both the anxious child and his/her parents. Children learn how to identify their anxiety, how to think more realistically, and to expose themselves to feared situations. Parents learn the same techniques as the children so that they are in a position to help their child in the coming years, and also learn different ways of handling and interacting with their child and ways of rewarding and motivating their child. Around 80% of children show marked improvement by the end of the program and effects continue for at least one year.

Q. Do anxious children have the cognitive ability to understand the principles of CBT?

Rapee: At Macquarie University we take children as young as 7 years. These children do just as well in our programs as do older children and there is no difference in outcome due to age. Most children are able to handle the concepts of thinking more realistically very well, but where there are difficulties. We focus more strongly on the exposure components and this works well. Parents are included to help their child master the strategies over time.

Q. What can parents do if their child refuses to see a therapist?

Most anxious children will agree that it would be better to worry less, have more friends, join clubs, and so on. Therefore, if it is explained to them clearly and simply, they will be able to go to a therapist without too many problems. It is especially important to emphasize that their parents will be with them and to explain fully what they can expect. In most cases, they will be anxious, but they will go along. As a parent, we need to remember that sometimes children need to go through a little distress in order to achieve something - they will not break. If a child completely refuses to go to the therapist, the parents should still go so that they can discuss some strategies with the therapist. Asking the child exactly what he or she is worried about, explaining exactly what will happen, offering a reward or incentive, and pointing out the benefits of going, are some strategies you could use.

Q. How can parents help their child deal with anxiety?

Rapee: The main help that a parent can give is to be supportive to the child while at the same time giving them space to make their own mistakes and learn for themselves. Taking over and doing everything for your child, protecting him or her from any possible harm, and reassuring him/her constantly only serve to keep the anxiety going. Aside from this, commonsense strategies are best but need to be used consistently. You need to teach your child to look at situations logically and to stop thinking about all the negatives. When a child reports a worry, ask them questions that will hopefully point out how unrealistic that thinking is. For example, "have you ever heard of anyone else doing that", "has it ever happened to you before", "would you do that to someone else", and so on. In addition, if your child fears a situation, you need to break the situation down into small steps and, in a systematic way, get your child to perform each step. Make sure you reward your child for trying his or her best.

Q. Can you tell us about the Macquarie University Clinic?

Rapee: The Child and Adolescent Anxiety Clinic at Macquarie University has been running for over 4 years and is aimed at helping children and their families with any type of anxiety disorder. We see children between 7 and 16 years for whom anxiety is their main problem. Following a thorough assessment, the children and parents are included in a treatment program that goes for 9 sessions over 11 weeks. The program teaches practical skills and strategies for the children to learn to manage their anxiety and parents are taught ways of helping them. At the end of treatment, approximately 80% of the children are markedly improved and these effects continue for at least a year (which is as far as we have followed people).

We have set up a similar program at Royal North Shore Hospital to demonstrate that similar results can be found in a general community setting. In addition, with the help of a Rotary grant we briefly ran an intensive, one week program for children from rural NSW. These children came to Sydney and went through a similar program that was run over a single week on a daily basis. This gave these children from distant and remote areas a chance to have access to this type of program. Unfortunately, funding was stopped after one year, so the program has closed. We have also conducted workshops for professionals in many places, including Melbourne, Newcastle, Brisbane, Adelaide, Sydney, and Orange so there are growing numbers of psychologists and school counselors who are learning about these techniques.

Q. Is there a trend in Australia, as there seems to be in the USA, to use medications for children's anxieties. Does this have negative effects?

Rapee: The USA is strongly medically oriented and there is a strong pressure to find drug "cures" for everything. Luckily in Australia, we do not have this degree of pressure. While many medical practitioners do prescribe medication for anxious children, this is not as common a practice as in the United States, probably largely because of public pressure against prescription. We do not know whether these medications are harmful, and there may be circumstances under which they are very useful. But given the excellent effects that we are able to get with non-medical treatment, there seems to be no need for medication in anxious children. In addition, the aim is to teach children skills that they can carry with them throughout their life to prevent a lifetime of anxiety. The effects of any medication stop as soon as the person stops taking it.

Q. Is school phobia the same as panic disorder?

School phobia refers to children who refuse to go to school because of anxiety. It can vary from children who miss the occasional day, to those children who do all of their schooling at home.

Children may fear going to school for many reasons and a thorough assessment is necessary to decide on the most important reason and the best course of action. The most common reason children avoid school is because of a fear of leaving an important person (usually their mother). These children often worry that something terrible will happen to Mum while they are away. In most cases this will be diagnosed as separation anxiety disorder and is a very different problem to panic disorder.

While it is possible that some children may avoid school due to panic attacks, panic disorder is actually very rare in children before the late teens. Children can certainly "panic" - so do we all. But this is different to what we mean by the diagnosis of panic disorder. The main characteristic of panic disorder is unexpected panic attacks. These are characterized by a sudden rush of fear, several physical symptoms (e.g. pounding heart, breathlessness, chest pain), and beliefs that you are going to have a heart attack, die, or pass out. Children will very rarely report these types of episodes.

Q. Will there be an Anxiety Disorders awareness campaign in the future?

We are not planning such a campaign because it requires a lot of funding and is not in our brief. However, it is a very good idea. Organizations such as the Anxiety Disorders Foundation and Panic and Anxiety Disorders Association are precisely the types of groups who should be doing this sort of thing. The more education that the public and professionals can get about anxiety, the better and knowledge about children's anxiety is especially limited.

As our part of the equation, we do run workshops for professionals teaching to identify anxiety disorders and about our treatment program. In addition, we are often asked for opinions in the media about these problems and there are growing numbers of newspaper, magazine, radio, and television programs reporting on these problems in children. Finally, we are currently in the process of writing books on recognizing and treating anxiety in children, both for professionals and the general public, which will hopefully be completed toward the end of the year.

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