case study of a child with anxiety disorder

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Hannah, an anxious child

Hannah (not a real person) was a 10-year-old girl from a close, supportive family who was described as 'anxious from birth'. She had been a shy, reserved young girl at pre-school, but she integrated well in grade 1 and began making friends and succeeding academically. She complained several times of severe abdominal pain that was worst in the morning and never present at night. She had missed about 20 days of school during the previous year because of the pain. She also avoided school excursions, fearing the bus would crash. She had difficulty falling asleep and frequently asked her parents for their reassurance.

Hannah was worried that she and members of her family might die. She was unable to sleep at all before a test. She could not tolerate having her parents on a different floor of the house from herself, and she insisted on securing the house to an unnecessary extent in the evenings, fearing intruders. Her insecurity, need for constant reassurance, and school absenteeism were frustrating and upsetting for her parents.

Hannah had no personal history of traumatic events. She exhibits symptoms typical of childhood anxiety disorder, which is thought to occur in about 10% of children, equally in boys and girls before puberty. This type of disorder is diagnosed when anxiety is sufficient to interfere with daily functioning, for example Hannah's school attendance and sleep. These effects can increase and interfere to a progressively greater extent with age-appropriate functioning at home, at school and with peers, and also places sufferers at risk of developing mood disorders or substance abuse disorders in the future.

Many children experience fears; fears that are developmentally normal. Children with anxiety disorders, however, experience persistent fears or other symptoms of anxiety for months. Children can experience all the anxiety disorders experienced by adults. However, they can also experience separation anxiety disorder and selective mutism (failure to speak in certain social situations, thought to be related to social anxiety), which are unique to children. The duration of Hannah's difficulties and the symptoms, including inability to sleep, attend school regularly, go on school excursions, or face tests without extreme distress are all developmentally inappropriate, suggesting an anxiety disorder.

There is a range of common symptoms seen in anxious children. Symptoms involving thoughts include worrying, requests for reassurance, 'what if.' questions, and upsetting obsessive thoughts. Common symptoms involving behaviours include difficulty in separation, avoiding feared situations, tantrums when faced with fear, 'freezing' or mutism in feared situations, and repetitive rituals, or compulsions. Common symptoms involving feelings include panic attacks, hyperventilation, stomachaches, headaches and insomnia.

To screen quickly for one or more anxiety disorders in children, four questions are often useful:

• Does the child worry or ask for parental reassurance almost every day?
• Does the child consistently avoid certain age-appropriate situations or activities, or avoid doing them without a parent?
• Does the child frequently have stomachaches, headaches, or episodes of hyperventilation?
• Does the child have daily repetitive rituals?

These questions address the main thoughts, behaviours and feelings related to anxiety seen in children.

Megan Rodgers wishes to acknowledge an article entitled 'Childhood Anxiety Disorders' written by Dr Manassis, a Staff Psychiatrist at the Hospital for Sick Children and the Center for Addiction and Mental Health in Toronto, Ontario, on which this article is based.

Written by Megan Rodgers ADAVIC Volunteer June 2004

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• Volume 32, Issue 6
• Very early family-based intervention for anxiety: two case studies with toddlers
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• http://orcid.org/0000-0001-5603-6959 Dina R Hirshfeld-Becker 1 , 2 ,
• Aude Henin 1 , 2 ,
• Stephanie J Rapoport 1 ,
• Timothy E Wilens 2 , 3 and
• Alice S Carter 4
• 1 Child CBT Program, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
• 3 Division of Child and Adolescent Psychiatry, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 4 Department of Psychology , University of Massachusetts Boston , Boston , Massachusetts , USA
• Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}partners.org

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

• childhood anxiety disorders
• preschoolers
• cognitive behavioural therapy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/gpsych-2019-100156

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Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

• View inline

Application of treatment protocol with both participants

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

Quantitative changes in diagnoses, coping ability, symptoms and family function in both participants

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Acknowledgments

The authors acknowledge Jordan Holmen for assistance with data checking.

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Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

Patient consent for publication Parental/guardian consent obtained.

Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Melissa M. Doyle; Anxiety Disorders in Children. Pediatr Rev November 2022; 43 (11): 618–630. https://doi.org/10.1542/pir.2020-001198

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Anxiety disorders are the most common mental health disorders in children with clearly defined and empirically based treatment. However, assessment and treatment pose several obstacles for pediatric providers. A child who may have age-appropriate communication skills will still struggle to accurately report the presence, timing, and severity of symptoms. Reports from parents, caregivers, and teachers are often subjective and can focus on 1 aspect of the child’s behavior. Untreated, anxiety disorders have an adverse effect on a child’s functioning, and impairments in physical health, academic performance, and social competence can lead to lifelong consequences. Well-validated and rapidly administered screening tools can be used to gather data from schools and other resources to inform the diagnosis, guide treatment recommendations, and track improvements. Limited training on behavioral health diagnosis and fear of “black box warnings” have left many pediatric clinicians reluctant to prescribe medications. There are readily available practice guidelines for these medications, and data documenting the efficacy of these medications for children should encourage their use.

Pediatricians are being asked to assess, diagnose, and treat children with anxiety disorders at increasing rates, but most report low confidence and note a lack of training in this area. Clinicians should be aware of available screening tools, the range of treatment options, and current recommendations for medication for children.

List common pediatric anxiety disorders and their symptoms.

Identify screening tools that can be used in the office setting to diagnose anxiety disorders.

Recognize the most common treatment interventions.

Use practice guidelines to determine when and how to initiate a medication trial.

Anxiety often describes expected feelings of worry or nervousness in response to stressful or uncertain situations. Anxiety disorders are differentiated from worry or nervousness by the frequency of perseverative thoughts and resulting physical symptoms that impair function. Anxiety is the most common mental health diagnosis in children and adults, presenting in 2% to 20% of children across childhood, and typically affects achievement of developmental milestones and skill development. ( 1 )( 2 )( 3 )( 4 ) Signs and symptoms of an anxiety disorder can begin during the preschool period and continue through childhood. ( 1 ) Despite evidence that anxiety is the most common mental health disorder for children, only 1 in 5 children are diagnosed and treated. ( 5 ) Anxiety’s effect on children is typically noted in all areas of function, including learning and academics, peer interactions, and social activities. Children with undiagnosed or untreated anxiety report more physical symptoms and higher levels of stress and demonstrate overall poorer coping than children without anxiety. In addition, children with anxiety often develop other mental health diagnoses, such as depression and mood disorders, and engage in self-harm, substance use, and suicide. ( 3 ) Pediatricians, knowing the family history, are in a unique position to track changes in the child's development and function over time and can engage the family in a discussion about the diagnosis of anxiety and can encourage treatment.

Anxiety disorders are the most diagnosed disorder in children, with a reported prevalence of 10% to 30% of the population at any given time. ( 6 ) As with most psychological disorders, there is a complex interplay of biological, temperamental, and environmental factors that affect the development of an anxiety disorder. Parental anxiety disorders are associated with an increased risk of an anxiety disorder in affected parents’ children. ( 4 ) Magnetic resonance imaging studies have demonstrated both structural and anatomical differences for children with anxiety, which specifically affect the child’s ability to accurately perceive threats and regulate emotions when stressed. ( 4 ) Onset of an anxiety disorder typically occurs between ages 6 and 11 years, and in adults with diagnosed anxiety disorders, 15% to 30% were diagnosed during childhood. ( 3 ) Anxiety disorders can remit over time with an accompanying improvement in function without counseling or medication. However, the long-term effect on the child from lost time in school and with peers and the emotional and financial strain for parents should encourage the primary care provider to aggressively treat the child until symptoms abate. The temperament of both the child and parents should be noted, particularly when observing interactions within the child-parent dyad. A cautious child paired with an anxious or similarly cautious parent can result in the child avoiding novel situations. Anxious parents need support to manage their own anxious reactions, encourage the child to try new skills, and help the child practice strategies to mitigate anxiety. ( 1 )( 2 )

A child younger than 5 years can contribute little to the evaluation process due to immature speech skills and a poor ability to reflect on their own emotions. Evaluation of mental health conditions, including anxiety, must rely more heavily on data from a variety of sources, including parents, school, and other caregivers. Before adolescence, children may also struggle with articulating their internal experience, more often citing physical complaints such as headache or stomachache, or other functional impairments, such as interrupted sleep or poor appetite, rather than reporting anxiety. ( 3 ) Adolescents are typically more skilled with articulating their experience of anxiety symptoms. However, the teen may not recognize or report persistent symptoms having simply grown to tolerate these symptoms despite functional impairments. It is important to recognize that anxiety is a normative response to stressful circumstances and is developmentally typical at certain ages and stages. Anxiety serves as a critical safety mechanism to identify dangerous situations, which then triggers a physical "fight or flight" response for safety. However, further evaluation and treatment may be needed for the child who seems continually anxious, seems to overreact to events, or cannot engage in functional skills such as sleeping or going to school. ( 2 )

In addition, anxiety should be expected when the child is facing a new skill or challenge. For example, infants typically demonstrate fear of strangers, sudden or loud noises, and separation. These fears are developmentally normal and functional, resulting in the child seeking comfort from the caregiver. Preschool children typically describe fears of the dark, separation, storms, other sudden and unpredictable events, and monsters. At this age we often see a marked contrast between clinging to the caregiver in response to a sense of vulnerability with a burgeoning desire for more independence and control. School-age children often continue to express fears of the dark, monsters, and being abandoned, in addition to newer concerns about social and academic competency. Adolescents, with developing capacities for abstract thinking, often can imagine a myriad of negative consequences or perceived failures, or "fear of fear," which can restrict social interactions and hamper skill development.

Anxiety disorders are often comorbid with several other psychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD), depression, and mood disorders. Notably, 11% to 40% of children have comorbid anxiety and ADHD. ( 2 ) Diagnostic evaluation may be complicated because symptoms such as restlessness, difficulty concentrating, and inattention may be indications of any of these disorders. Furthermore, the child may experience poor sleep habits, changes in appetite, and, specifically with anxiety or depression, less enjoyment with preferred tasks. Because behaviors may also present in multiple settings, it is helpful to have parents and teachers track specific factors such as when symptoms present, the setting, the presence of other factors such as environmental stress, time of day, and the demands on the child. These factors can help clarify the diagnosis. For example, the child who reacts mostly in response to a specific stimuli or demand, such as seeing a needle in the doctor’s office or separating from a parent, is more likely to have anxiety. Children with any of these disorders may appear agitated or overstimulated in a crowd such as at a birthday party, a large shopping mall, or the school lunchroom. However, the child with ADHD is less likely to avoid or fear these situations because the child may not recognize or feel upset about their poor self-regulation. Children with ADHD often are distracted by other children, items in their desk, or a chaotic setting such as the lunchroom. Children with depression may want to avoid these situations or act irritably, but the underlying response is not fear of the situation but a lack of interest or enjoyment. The child with anxiety may also appear distracted in a large or chaotic setting. However, typically the child is more internally focused on their own worries.

Elements in the child's environment should be reviewed to identify factors that support and promote resilience. A child whose caregivers are physically and emotionally stable with few concerns about housing, food security, and safety in their neighborhood are better able to manage other stresses. Children from lower-income families are likely to have other health disparities as well, increasing their risk of stress and anxiety. Assistance may be needed from the primary care provider to access mental health care to mitigate the potential effect on these children’s physical and mental health, academic achievement, and social outcomes. ( 7 )

Evaluating a child for anxiety poses significant challenges for the primary care provider. Symptoms of anxiety disorders in children also present broadly across other mental health diagnoses common in this age group. These symptoms include changes in patterns of eating, sleeping, and school function; social interaction issues; and avoidance of typically enjoyed activities. ( 6 ) The child’s temperament and environmental modeling are often factors in how symptoms are reported, which affects the diagnostic process. Some children present with more internalizing symptoms, that is, symptoms directed inward, which may not be as evident to an observer. Internalizing symptoms include withdrawal from activities, vague pain symptoms, or somatic complaints such as stomachaches. Other children have more externalizing symptoms that are evident in their behavior or attitude or are directed at others. Examples of externalizing symptoms include irritability, tantrums, or behavioral outbursts. These symptoms warrant a medical evaluation to rule out medical concerns, although anxiety should be included in the differential diagnosis. Screening tools that can be completed rapidly during an office visit, garner information from various sources, and offer ease of interpretation can be an effective strategy for gathering objective data to aid the diagnostic process. There are many screening tools available for the primary care office. Three of the most widely used and free of cost will be cited herein, although this information is not intended to be an exhaustive list. Primary care providers are encouraged to choose a well-validated screening tool that is simple to administer and is written in clear and understandable language with clear instructions for a more thorough assessment when indicated. Table 1 summarizes some of the more commonly used tools and references where they can be located.

Screening Tools for Pediatric Anxiety

ADHD= attention-deficit/hyperactivity disorder, GAD=generalized anxiety disorder, OCD=obsessive-compulsive disorder, PTSD=posttraumatic stress disorder.

The following subsections provide a summary of the most common anxiety disorders diagnosed in children. Although specific anxiety disorders can appear at any age and may not be linked to an earlier presentation of anxiety, a developmental timeline offers a useful tool for organizing the following discussion.

Separation Anxiety

Separation anxiety is the fear of separation from the parent or caregiver and is developmentally normal for children during infancy through toddlerhood. After this time, the child has achieved object permanence and can recognize that the parent returns after leaving. Children of this age without anxiety can effectively use a coping strategy to allay their fears until the parent returns. Separation anxiety should be considered for the child whose fear or distress cannot be soothed and persists even after the parent returns. These children often have a history of struggling to sleep alone, having nightmares about parental abandonment, following the parent or caregiver when they leave the room even in their own home, and complaining of physical symptoms when anticipating the parent leaving. ( 13 ) Typically, parents report difficulty with separation during preschool or early school years. Time away is typically marked by repeated checking in with the parent for reassurance and encouragement. When this struggle persists into school age or early adolescence, children may struggle with sleepovers at friends' homes and attending school or camp functions.

Selective Mutism

Selective mutism is a relatively rare disorder in which the characteristic feature is the child’s refusal to talk entirely or speaking only in whispers in social situations, typically outside of the home. Selective mutism is often first reported during the preschool years. These same children are reported to speak comfortably and without prompting when in familiar environments such as in the home or with family members, even when there are larger groups. Data about the child’s interactions in a school or other setting away from parents will help differentiate this diagnosis from separation anxiety. The child with selective mutism may not protest separation from the caregiver as much as the child will refuse to or only minimally speak outside the home. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ) diagnostic criteria include that these children do not initiate speech and fail to respond when spoken to by others in certain situations, such as in school or unfamiliar settings. ( 13 ) The failure to respond cannot be due to a lack of knowledge or discomfort with the language being spoken, must have a duration longer than 4 weeks, and must interfere with academic achievement and social interactions. ( 13 ) Selective mutism can co-occur with other anxiety disorders, and a careful history of a child presenting in school age or adolescence with symptoms of anxiety should include information about early preschool speech. These children often meet the diagnostic criteria for social phobia in later childhood or early adolescence. ( 14 ) The differential diagnosis should include learning disorders, hearing impairment, functional speech impairment, or the primary language is not the spoken language.

Social Anxiety Disorder

Social phobia or social anxiety disorder is most often reported by school-age children 6 to 12 years old. The DSM-5 diagnostic criteria require that the child experience marked distress and fear of judgment by others, which must include peers and not just adults, in social situations. To diagnose social anxiety in a child, the provider needs to document symptoms that have lasted longer than 6 months, note that the child’s reactions are disproportionate to social events, and there is a struggle to function in academic and social situations. ( 13 ) These children avoid social gatherings and time with friends and may be labeled by teachers or peers as withdrawn or shy in the classroom. Other children may manage the distress through acting out, crying, or having tantrums. When asked, the child often can cite an event when the child was embarrassed or humiliated, which becomes a point of fixation with the belief that it will reoccur if the child is in public again. Often the child will have anxiety symptoms when discussing the real or imagined future event, including racing heartbeat, sweating, or shaking, that further reinforces their struggle in social settings. ( 14 ) Evaluation should include questions about how vocal the child was in different environments, as selective mutism has been linked to a later diagnosis of social anxiety disorder. Additional diagnostic care needs to be taken when differentiating social phobia from autism spectrum disorder (ASD) because both present with difficulties with initiating and maintaining social demands typical for age. ASD tends to present earlier in development with a constellation of symptoms that include restricted interests, repetitive patterns of behavior, sensory sensitivities, inflexible adherence to routines, and difficulties with perspective taking or seeing the world “through the eyes of another.” These symptoms typically are not the result of social phobia, which tends to emerge during the early elementary years when there are increasing demands for peer and social interactions. An important consideration is that individuals with ASD are not afraid of social interactions, they may simply not prefer them, whereas the fear of social interaction is a principle component of social phobia. ( 2 )

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a persistent state of unease that can be marked by vigilance and hyperarousal that occurs in multiple settings, including home and school, and with friends. Children are typically driven to repeatedly seek reassurance from caregivers, teachers, and others and often struggle to identify a specific trigger or stressor for their worried state. The DSM-5 criteria require that the excessive worry persists for more than 6 months, is difficult to control, and is accompanied by 1 of the following symptoms: edginess or restlessness, fatigue, impaired concentration, irritability, muscle aches or soreness, or difficulty falling or staying asleep. ( 13 ) The report of intrusive thoughts that feel "stuck" is common with both GAD and obsessive-compulsive disorder (OCD), which can complicate diagnosis. ( 2 ) The content of the perseverative thoughts is key when differentiating between GAD and OCD. Children with GAD tend to perseverate more about normal occurrences, such as a school test or sports tryouts. Children with OCD tend to fixate on a terrible event, such as the death of a parent, if they do not behave perfectly or that the child's anger toward a sibling will result in their harm. ( 2 ) For the child with GAD, it is the persistence of the thought, rather than the content, that is most distressing. Children with GAD also demonstrate signs of perfectionism, struggle with criticism, need continual reassurance, and express fears of negative consequences.

Obsessive-Compulsive Disorder

OCD includes 2 core symptoms that often occur in a cyclical pattern. Obsessions are thoughts that are recurrent, persistent, or perseverative. The child struggles to distract from these thoughts, which often leads to distress. In GAD, perseverative thoughts are often about common life events such as test performance. With OCD, the content of the child’s thought tends to be extreme and harmful, such as believing that a parent will die if they do not perform a certain behavior. Compulsions are repetitive behaviors believed to avoid harmful outcomes and often reduce the child’s distress when performed. The child with OCD may believe that an extended goodbye ritual will prevent harm to a parent or sibling while they are apart. After engaging in the goodbye ritual, the child often feels relief. This relief compels the child to repeat this ritual every time the child experiences obsessive thoughts. The pattern of obsessive thoughts and compulsive behaviors interrupts daily function in school and home or with friends. The diagnosis of OCD according to DSM-5 diagnostic criteria indicates that the child experiences obsessive thoughts or engages in compulsive actions for at least an hour every day, the child does not feel able to stop the thoughts or compulsive actions, and these thoughts or actions interfere with school, social, or other life functions. ( 13 ) Children with OCD often present with a comorbid depressive disorder or other anxiety disorders.

Specific Phobia

Specific phobia is considered when the child has a marked fear or anxiety focused on a certain situation or object. The most common specific phobias in children include vomiting, thunderstorms or other extreme weather situations, bees or other stinging insects, and injections or other medical treatments. ( 14 ) In addition to the focus on a certain trigger, the DSM-5 diagnosis requires that the fear has lasted for at least 6 months and is out of proportion to the potential danger to the child, the child avoids the fear trigger or situation, and function is impaired at home, at school, and with peers. ( 13 ) For example, a child with a needle phobia often questions the parent relentlessly about getting a shot and finds it difficult to be comforted or redirected. Children with medical fears such as injections or blood draws may experience a vasovagal fainting or near fainting episode when they talk about an event when this may occur. ( 14 ) A child with a specific phobia will often try to avoid facing the feared stimuli, such as not wanting to go to the doctor’s office if the child has a needle phobia or avoiding being outside if the child has a phobia of bees. Specific phobias are more common in girls when there is a family history of anxiety disorders, tend to first appear in late school-age children, and often co-occur with other anxiety disorders. ( 15 )

Panic Disorder

Panic disorder is often described as a surge of anxiety accompanied by debilitating physical symptoms. The DSM-5 criteria specify that panic attacks can be either expected, due to the presence of a known fear (such as flying), or sudden, which do not seem to be connected to a specific trigger. The reaction is described as an “abrupt surge or intense fear or discomfort accompanied by four or more of the following: sweating, shaking or trembling, racing heartbeat, chest pain, feeling faint or dizzy, nausea, stomach pain, and the need to urinate or defecate.” ( 13 ) Often the child can describe an event or situation when the child fears a panic attack, and that thought alone triggers a panic attack even when the child is not facing the stressful circumstance. These children begin to avoid social events or other situations not because they are fearful of social interactions but to avoid another panic attack. Panic disorder is most closely related to social anxiety disorder because in both instances children tend to focus on an actual or imagined social event when they experienced anxiety. However, those with panic disorder will avoid social events to avoid another panic attack, whereas the child with social anxiety will avoid social events because of feeling judged by others or under scrutiny. Panic disorder can be differentiated from GAD as the symptoms with panic disorder are sudden and extreme with physical symptoms, without a persistent feeling of anxiety. Panic disorder can be differentiated from OCD by the content of thoughts that are focused on medical symptoms or conditions and not on fear of harm to others. Panic disorder most often presents in adolescents rather than in younger children. When undiagnosed or untreated, the ongoing avoidance of social situations can precipitate agoraphobia, a fear of being out in public. ( 14 )

Successful treatment of an anxiety disorder should include a combination of psychoeducation of the parent or caregiver and the child, behaviorally based therapy, and, if the child’s function is severely affected, medication. Psychoeducation for both the parent and the child is critical for treatment success. The parents need to recognize how they have changed their actions to manage the child’s fear. For example, the parent who knows the child is anxious about going to school may start driving the child to school believing that such action will help the child feel less worried. The parent’s accommodation often serves to reduce both the parent’s and child’s anxiety. However, this accommodation creates a pattern in which the child avoids facing the feared situation, does not need to develop strategies to manage anxiety, and can develop a dependency on the parent’s presence to help the child manage the worry. The parent will need to understand how important anxiety coping strategies are for their child’s success. Parents can be coached on specific behaviors they can model to ensure that the child is successful when trying new approaches.

The most common behavioral therapy for anxiety is cognitive behavioral therapy (CBT). CBT has demonstrated greater overall effectiveness for the treatment of anxiety in children than medication alone or placebo. ( 17 ) Typically, CBT approaches for children include helping the parent and child restructure anxious cognitions into more logical thoughts and build strategies for relaxation. A child, afraid harm may come to the parent after dropping the child off at school, would be helped to develop a repeated message with a more logical focus, such as “my parents come back for me every day at the end of school.” The parent would be coached to repeat this message whenever the child raises a concern about drop-off and then practice relaxation or distraction strategy together with the child. For the child with a fear of bees that impedes playing outside, the family would be helped to reframe this fear into a more logical understanding that “bees are not out to get me, they are just looking for flowers.” Often included in successful counseling are exposure trials, or planned times when the parent and child would practice this skill. This "homework" may include reading a book about how bees find their food from flowers and then practicing going outside for prescribed periods. These planned “exposures” help the parent and child tolerate the anxious feelings, build a feeling of competence facing the feared stimuli, and overall feel more accomplished. CBT and other therapies, when practiced and reinforced, have demonstrated efficacy after a short course of treatment, such as 6 to 12 sessions. Treatment is often dictated by the cognitive maturity of the child. Therapy with younger children often consists of fewer sessions, with a greater focus on parent interventions. Over time, the child can more actively engage in therapy when the child develops the ability to recognize anxious thoughts and can cue a more adaptive strategy. For example, a 6-year-old with separation anxiety will rely on their parent to verbalize their anxious thoughts and recognize their increasing physical distress, and then model more adaptive coping. That same child at age 9 years is better able to verbalize their thoughts but likely will need the parent or teacher to help the child identify when the child struggles, such as at drop-off or when the school schedule changes, and then prompt the child to practice coping strategy. By age 12 years, the child can anticipate situations that will be stressful and can engage in some proactive planning when the child can cite what coping strategy should be used. By later adolescence, the capacity to generalize these skills to unknown future situations will have developed, and the child may be able to successfully navigate anxious situations without therapy support.

Cognitive therapy, including exposure treatment, and psychoeducation for the child and family are strongly recommended as first-line treatment for mild anxiety disorders. Therapy can take some time before improvement in symptoms is evident, and the child and family may need encouragement to continue, rather than feel distressed and hopeless. If there is no significant improvement in function after 8 to 12 weeks of therapy with a fully engaged and compliant family and child, first a change of therapists or therapy interventions should be considered. However, if the child’s symptoms are rapidly escalating or functional skills are decreasing, or the child and family are becoming more distressed and hopeless, a trial of medication should be considered. Significant functional impairment such as poor sleep or appetite or inability to attend school or engage with peers should be considered signs of moderate or severe anxiety. ( 3 ) A medication trial is likely needed to provide enough symptom relief to engage in therapy and provide hope that change is possible. The limited number of randomized controlled trials (RCTs) of medication for anxiety in children offers some research data on which agent is preferred for children at certain ages or for specific anxiety disorders. ( 3 )( 4 )( 6 ) Practice consensus and provider experience, combined with family history of effective selective serotonin reuptake inhibitor (SSRI) response, often guide prescribing practices. Some medications come in pill form only; children who cannot swallow pills will need to choose among the liquid formulations.

The most common medications used in children with anxiety disorders are SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, and atypical anxiolytics. A review of RCTs by Lichtor and colleagues ( 16 ) reported that sertraline demonstrated efficacy for GAD, social anxiety disorder, separation anxiety disorder, and selective mutism; paroxetine for social anxiety disorder; and fluvoxamine for GAD, separation anxiety disorder, and social anxiety disorder. Despite an increase in RCTs to evaluate medications in pediatric anxiety, only duloxetine has Food and Drug Administration (FDA) approval for use in GAD in pediatric patients, although given its low reported benefit and adverse effect profile, it is not considered a first-line medication. ( 6 )( 17 )( 18 ) SSRI medications act by preventing the reuptake of serotonin into presynaptic neurons and enhancing serotonergic neurotransmissions. ( 6 )( 18 ) Venlafaxine and duloxetine are SNRIs, which block both serotonin and norepinephrine reuptake and weakly inhibit dopamine reuptake. Venlafaxine can act similarly to an SSRI at lower doses and as an SNRI at higher doses, ( 6 ) although venlafaxine is not FDA approved for use in children. SNRIs are not typically a first-line treatment for anxiety in children, often being trialed only if initial SSRI medications have failed. Although less well-studied than SSRIs, SNRIs have demonstrated treatment efficacy for primary anxiety symptoms, although they have less reported remission and response compared with SSRIs. ( 17 ) A comparison of medications, their common starting and titrating dosages, and their adverse effects can be viewed in Table 2 .

Psychopharmacology for Anxiety Disorders in Children

ADHD= attention-deficit/hyperactivity disorder, OCD=obsessive-compulsive disorder, SNRI=serotonin-norepinephrine reuptake inhibitor, SSRI=selective serotonin reuptake inhibitor.

Common adverse effects for all SSRI and SNRI medications include gastrointestinal distress, headache, decreased appetite, difficulty initiating sleep, and somnolence. Activating adverse effects may be seen particularly in younger children. All these medications carry a regulatory or “black box” warning of potential for increased suicidal ideation, and discussion of this with caregivers and oversight by clinicians is strongly encouraged. Recommended dosages are based on reports from randomized controlled trials in children with varying anxiety diagnoses and clinical experience. Most SSRI and SNRI medications are not Food and Drug Administration (FDA) approved for use in children, although they are often used when the potential benefits outweigh the risk of not prescribing.

Adverse effects for all the SSRI and SNRI medications are similar. Children frequently are bothered by gastrointestinal adverse effects such as stomachache, nausea, and dry mouth. Other children report behavioral activation such as feeling "jumpy,” irritable, or agitated or may report a change of mood. Activation is often seen with initiation of medication or change in dosage and typically subsides after an initial period. Difficulty with sleep initiation or frequent waking may also occur with increased serotonin levels. Good sleep hygiene, taking the medication in the morning, and taking melatonin for sleep initiation often are useful strategies. Most adverse effects can be reduced or eliminated with a reduction in dosage. The report of persistent weight gain may lead to reluctance of teen girls to take SSRI medications. For older teens, a decrease in libido is an adverse effect that should be discussed to avoid the patient stopping medication use abruptly if this occurs. There are increased hypertensive risks for SNRIs, in addition to the other standard adverse effects of SSRIs, necessitating ongoing monitoring of blood pressure when prescribed. ( 6 ) Serotonin syndrome is a rare adverse effect caused by excessive serotonergic neuronal activation, and it most commonly occurs when the patient is taking high doses of multiple SSRI medications. ( 6 ) Typically, response occurs within hours of taking the increased dosage. The true incidence of serotonin syndrome remains unclear because most mild cases are unreported and respond to a decrease in medication. Patients may note a range of effects, including mental status changes such as agitation and confusion, increased neuromuscular activity, tachycardia, hypertension, tremors, and autonomic instability, including fever, shivering, excessive sweating, diaphoresis, and diarrhea. ( 6 ) When serotonin syndrome is suspected, medications should be stopped immediately and urgent medical care provided.

Suicidal ideation remains a concern for prescribers, particularly for children with a history of depression or suicidal ideation. The "black box warnings" following a 2004 FDA study of children taking SSRIs who reported an increase in suicidal statements led to considerable reluctance by many practitioners to prescribe and parents to agree to medications for their children. However, subsequent research and clinical practice has demonstrated that these medications, when monitored, can be used safely for many children, particularly when there is no history of suicidal thought. ( 3 )( 6 )( 16 ) Children should be asked about suicidal thoughts and cautioned to report any increase in agitation or activation when medication is initiated and with any change in medication dosage.

Buspirone is a serotonin 1A receptor partial agonist, which increases action at the serotonin receptors in the brain. Some prescribers are using buspirone in addition to other medications to treat anxiety. Buspirone has few adverse effects, including headache, dizziness, nervousness, drowsiness, and nausea, which tend to abate quickly, and is not associated with withdrawal symptoms. These factors have led to some using it as a first-line treatment for anxiety or in conjunction with another SSRI medication. ( 6 ) Prescribing benzodiazepines is discouraged because there is little reported evidence of efficacy and because of adverse effects and increased likelihood of tolerance with long-term use. ( 16 ) In addition, there are no current RCTs that demonstrate its effectiveness, and it is not FDA approved for use in children. ( 16 ) Primary care providers, particularly those in underserved regions, often have few colleagues or resources for consultation when diagnosing a child with a mental health disorder and when prescribing medication. Online resources that provide case consultation and guidance on prescribing can be a valuable resource. One such source is the Center for Mental Health Services in Pediatric Primary Care through Johns Hopkins University ( http://web.jhu.edu/pedmentalhealth/nncpap_members.html ).

After 12 weeks of no improvement after maximizing dosing, consider switching the agent.

After another 12 weeks without improvement, the primary care provider should evaluate compliance with the medication and rule out another medical, comorbid mental health, or substance use disorder.

Finally, consider switching to another SSRI or SNRI or augmenting by adding another agent to boost effectiveness.

Referral to a psychiatric level of care may be considered at any time at the provider’s discretion and encouraged if the child does not show improvement with therapy or medication trials.

Children with anxiety tend to require higher dosages of medication, and response may take longer than is reported by children with depression. There are no laboratory tests typically required when using an SSRI medication in a child or adolescent. Monitoring of medications is recommended weekly for the first month after starting medications, then at 4 weeks for the second month, and then at 12 weeks. Each appointment should include a review of administration to ensure that the family is dosing correctly and assessing for adverse effects and suicidal ideation. ( 3 ) Increasing the medication should occur after 4 weeks of treatment if no improvement is detected and should continue until symptoms are improved, adverse effects are too noxious, or maximum dosage is achieved. ( 6 ) Children's higher metabolisms may require twice daily dosing. Once symptoms have abated, it is recommended that the child remain on medication symptom free for 1 year before considering withdrawing medication. ( 18 ) A slow medication taper at that time should be performed during a stress-free time, such as the summer. ( 2 )( 18 ) Medication should be decreased to the next lowest dose available and continue at that level for at least 2 weeks and often up to 4 weeks. During this period, one should closely monitor the child for a return of symptoms. If symptoms reoccur, one should remain at that dose without further decrease until it is clear the child can tolerate any further future reductions. If the reduced dosage is well tolerated, then the medication should again be decreased to the next lowest dose for at least 2 weeks and up to 4 weeks, continuing the same pattern until the medication is discontinued. Nonmedication interventions, including therapy, parent support, and classroom modifications, should continue to support positive function during the medication taper. ( 2 )

Anxiety and Depression Association of America ( https://adaa.org/ ) (no cost)

UCLA Center for Child Anxiety Resilience Education and Support (CARES) ( https://carescenter.ucla.edu/ ) (no cost)

Child Mind Institute ( https://childmind.org ) (no cost)

Child Anxiety Tales ( https://www.copingcatparents.com/Child_Anxiety_Tales ) (subscription fee)

The Worry Workbook for Kids: Helping Children to Overcome Anxiety and the Fear of Uncertainty (An Instant Help Book for Parents & Kids) (Ledley and Khanna, 2018)

What to Do When You Worry Too Much: A Kid's Guide to Overcoming Anxiety (What-to-Do Guides for Kids) (Huebner, 2005)

Headspace ( https://headspace.com ) (free version)

Calm ( https://calm.com ) (free version)

Breathe, Think, Do with Sesame Street: targeted at children ages 0 to 6 years featuring several familiar Sesame Street friends learning emotional regulation skills to deal with a variety of life challenges (no cost)

Breathe2Relax: designed by the US Defense Health Agency, this free app is for teens and adults to learn diaphragmatic breathing to lower anxiety

Cosmic Kids: for children ages 3 to 9 years, this site offers yoga and mindfulness-based interventions (free version)

DreamyKid: there is a free version of this app to help kids ages 3 to 17 years with meditations

HappiMe for Young People: this free app is designed for children through teens to identify and challenge negative thoughts and emotions

Smiling Mind: this free app geared for different age groups builds mindfulness skills

Super Stretch Yoga: this free app guides young children through yoga stretches and breathing

Substantial previous research ( 1 )( 2 )( 3 )( 4 ) supports that anxiety is developmentally typical at certain ages and stages and becomes problematic only when it is persistent, is out of proportion, and impairs function.

Research evidence ( 1 )( 2 )( 3 )( 4 ) and practice consensus indicates that the assessment of anxiety includes input from parents, caregivers, and teachers to support the diagnosis, guide treatment recommendations, and track improvements over time.

Some research evidence ( 2 )( 3 )( 4 ) and practice consensus indicate that anxiety disorders can mimic other mental health disorders and co-occur with attention-deficit/hyperactivity disorder, depression, learning disorders, and other diagnoses.

Substantial research ( 3 )( 4 )( 16 )( 17 ) strongly supports psychoeducation and cognitive behavioral therapy as first-line treatment. Medication should be considered for symptoms that are moderate to severe or are rapidly escalating.

Limited randomized controlled trials in children ( 6 )( 16 )( 17 )( 18 ) and substantial practice consensus support selective serotonin reuptake inhibitors (SSRIs) as the first choice for children. Provider experience, family history, and the child’s ability to swallow pills guides the choice of SSRI medication.

The existing literature ( 1 )( 6 )( 16 )( 17 )(19) and practice consensus support increasing medication dosage every 4 weeks until either improvement or significant adverse effects develop. No improvement after 8 to 12 weeks should trigger the use of another agent, consideration of other comorbidities, and referral for psychiatric evaluation.

Limited research evidence ( 2 )( 6 ) and practice consensus suggest withdrawing medication only after 1 year with no reported symptoms. Medication dosage should be reduced to the next lowest dose available for 4 weeks, and if no increase in symptoms, reduced again to the next lowest dose available for 4 weeks, continuing until the dosage is discontinued.

AUTHOR DISCLOSURE:

Dr Doyle has disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Generalized anxiety disorder in kids.

When near-constant worry affects your child’s well-being

Writer: Shelley Flannery

Clinical Experts: Emily Gerber, PhD , Jerry Bubrick, PhD

What You'll Learn

• How is generalized anxiety disorder different from other forms of anxiety?
• What do kids with generalized anxiety disorder worry about?
• How can we help kids with generalized anxiety disorder?

Most kinds of anxiety focus on a particular worry — fear of heights, separating from parents, speaking in public, things like germs or spiders.  But some kids are anxious about many things. They have what’s called generalized anxiety disorder or GAD.

Kids with GAD worry about everything, and it often takes the form of “what ifs”:

“What if we run out of gas?

“What if mom loses her job?

“What if a hurricane blows away our house?

“What if I get a bad grade?”

Kids with GAD tend to imagine the worst happening, and  their anxiety may not be triggered by anything in particular. They may be irritable and have trouble sleeping.

Kids with GAD also tend to be perfectionists. They may put enormous pressure on themselves to perform well — more than their teachers or parents — and may avoid doing things because they’re worried about not doing them well enough. They may have anxious stomachaches and headaches and spend a lot of time in the school nurse’s office.

It’s important to get help for kids with GAD because all that worry can lead to depression, and it also leads, for teenagers, to substance use —drinking alcohol or smoking pot to ease their anxiety.

Treatment for GAD includes cognitive behavior therapy (CBT), in which kids learn to recognize irrational thinking and replacing it with more logical, healthy ways of thinking. An alternative is acceptance and commitment therapy (ACT), which teaches kids to acknowledge and accept the anxious thoughts they’re having and commit to moving forward despite them. Parents also learn how to avoid enabling their child’s anxiety and instead support their overcoming it.

Severe GAD may be treated with a combination of therapy and medication, usually an antidepressant called an SSRI.

For a lot of kids with anxiety, excessive worry is triggered by a specific situation, such as being away from their parents, public speaking, heights or a scary animal. But kids who worry excessively about numerous things may have generalized anxiety disorder.

Generalized anxiety disorder (GAD) is characterized as constant worry about lots of different things that aren’t really threats and/or overreacting to minor threats. It’s the most common type of anxiety disorder among children and teens.

Unlike with a phobia, which has a specific trigger — spiders, needles, dogs, airplanes, clowns, etc. — children with GAD worry about a variety of everyday situations.

“Kids with generalized anxiety disorder worry about all the same things that other kids worry about,” says Emily Gerber, PhD , the senior director of the Anxiety Disorders Center at the Child Mind Institute’s San Francisco Bay Area clinic, “but they worry more often and more intensely.”

There doesn’t even necessarily have to be anything that triggers it, adds Dr. Gerber. “It’s sort of always  there.”

Si gns of GAD

“Kids with GAD are chronic worriers,” says Jerry Bubrick, PhD, a senior clinical psychologist at the Child Mind Institute. “There’s no area that they don’t worry about, but the typical areas of worry are usually around health of themselves or their family, money, and safety and stability.”

Kids with GAD worry about the “what if’s,” adds Dr. Bubrick.

“What if we run out of gas?”

“What if mom loses her job?”

“What if a hurricane blows away our house?”

They tend to imagine the worst happening, and seek reassurance from parents that it won’t.

Dr. Bubrick has seen kids, for example, who are super worried if a big storm is coming in. Then, if nothing bad happens, they’re worried about another storm coming. What if we’re not as prepared next time? They’re glued to the weather reports with excessive worry.

Dr. Gerber describes a child who developed GAD during the pandemic. “His aunt was in the ICU for a while during COVID, and so he started to become overly concerned about everybody around him,” she says. “He was constantly asking, ‘Are they going to be okay?’ and didn’t want anyone to go out because he was so worried they would get sick.”

Other signs of GAD in children and teens include:

• Restlessness or feeling on edge
• Apprehensiveness
• Indecisiveness
• Being easily fatigued, especially at the end of the school day
• Irritability
• Trouble sleeping
• Difficulty concentrating or feeling their mind go “blank”
• Catastrophizing or always expecting the worst

Kids with GAD are perfectionists

Most kids feel anxious about their performance in school from time to time and may worry about an upcoming test or presentation. A child with GAD, however, is likely to take that worry to an extreme, and study obsessively even though they already know the material.

“There’s one 9-year-old in particular I’m thinking of whose parents are very ambitious and so he only wants to get A-pluses at school,” Dr. Gerber says. “He has this terrible fear that if he submits an assignment and it’s anything less than perfect, his life is going to be ruined. As a result, he’s developed some avoidant behaviors. He either is distressed or he’s so avoidant that he completely forgets about the assignment.”

Dr. Bubrick adds that some kids with GAD are such perfectionists that they don’t want to do anything unless they can be the best at it. “They will think, ‘If I can’t be the best at something, then why try? If I can’t be a rock star, then why take guitar lessons?’ “

They may have anxious stomachaches and headaches and spend a lot of time in the school nurse’s office.

Who’s at risk?

GAD can develop in children as early as 5 but is most frequently diagnosed in adolescents. It tends to affect girls more than boys, but all genders can develop the disorder. Kids with sensitive temperaments are more likely than others to develop generalized anxiety.

The largest predictor of GAD in children and teens is family history. Kids who have one parent with any kind of anxiety disorder are more likely to have generalized anxiety than other kids; those with two parents with anxiety are significantly more at risk. Experts believe the risk stems from a combination of biology and learned behaviors — seeing how a parent deals with stress and worry and emulating that behavior.

And if there’s one thing kids today have an abundance of, it’s stress. Rates of anxiety had already been on the rise when COVID-19 hit the U.S. in March 2020. The pandemic accelerated the development of the disorder in many young people. Between 2016 and 2020, anxiety rates among kids had increased from 7.1% to 9.2%, according to a study published in JAMA Pediatrics whereas a review published just a year later in the Journal of Psychiatric Research reported rates of anxiety among kids were between 19% and 24%.

“The pandemic was a major anxiety trigger for a lot of Americans, especially kids, who rely on school for most of their socialization,” Dr. Gerber says. “And unfortunately, we have yet to see rates of GAD slow down. We’re still seeing kids with anxiety levels parents say they’ve not seen before.”

When GAD goes untreated

Without treatment, GAD typically worsens over time. If you suspect your child might have generalized anxiety disorder, it’s a good idea to get them evaluated. The sooner GAD is diagnosed and treated, the fewer long-term complications your child will develop.

“The danger is that if GAD isn’t treated and kids don’t learn how to cope with anxiety in safe and effective ways, it can continue to erode their functioning,” Dr. Gerber says. “It really can become chronic and is a strong predictor of depression and other disorders later in life.”

Another real concern, particularly for adolescents and teens, is substance use.

“There are a lot of kids — when they haven’t gotten treatment — who will self-medicate and start drinking alcohol or smoking pot to ease their anxiety,” Dr. Gerber says. “But a lot of times, the opposite happens. It might be a relief initially, but if they don’t learn to cope with the discomfort and develop skills for dealing with their feelings, then the anxiety will continue to increase and often so will the substance use.”

Treatment options

Most instances of GAD can be treated with psychotherapy in the form of cognitive behavior therapy (CBT) or acceptance and commitment therapy (ACT).

With CBT, children and teens are taught their worries are not based in fact and learn ways to cope with anxious thoughts when they arise. Exposure therapy, a CBT technique commonly used in the treatment of anxiety, involves triggering a child’s anxiety a little at a time, in a safe and controlled setting, until the anxiety subsides. Once a child has learned to tolerate the anxiety without avoiding it, the anxiety diminishes.

There’s a limit to what you can do with exposure therapy for kids with GAD, who are worried about so many things, notes Dr. Bubrick. “You can’t do exposures for everything all the time. So, we do a lot of cognitive work instead. We do a lot of challenging thinking, getting kids to recognize that irrational thinking and replacing it with more logical, rational versions of those thoughts. So, it’s really having the kids learn a different way to think.”

Teens, particularly those who have prior experience with CBT, may benefit from ACT, a form of mindfulness therapy closely related to CBT. With ACT, a teen would learn to acknowledge and accept the anxious thoughts they’re having and commit to moving forward despite them. ACT helps kids step back and observe their anxiety, Dr. Gerber adds. “Rather than trying to stop it, they’re, in a way, making friends with it, treating it like an uninvited guest who’s tolerable, if not exactly welcome.”

Mild to moderate GAD can often be treated in anywhere from 10 and 20 therapy sessions. Severe GAD is treated with combination psychotherapy and medication for anxiety disorders , usually an antidepressant called an SSRI.

“The medication might allow them to progress more quickly in the therapy because they can tolerate the intensity of the worry or the anxiety better,” Dr. Gerber adds.

What parents can do

While GAD tends to run in families, it’s important not to blame yourself for your child’s anxiety and instead focus on helping them work past their worries.

“A lot of times parents will feel like they did something wrong,” Dr. Gerber says. “In reality, many factors go into a kid developing GAD. I like to tell them ‘You’re not the problem, but you can be a big part of the solution.’”

That involves getting your child the treatment they need and working with your child’s therapist to learn how to best support your child outside of the clinician’s office. Step one is to avoid inadvertently reinforcing anxious behavior. Parents can unintentionally accommodate fears by providing reassurance or allowing kids to avoid things that trigger their anxiety.

“It’s quite natural for parents to want to provide reassurance or accommodate a child when they’re upset,” Dr. Gerber says. “But by doing that, you’re sending the message that there is something to be worried about.”

As an example, Dr. Gerber says she once had a patient who was scared to come downstairs for fear something bad would happen. His well-meaning parents “got a mini fridge and plugged it in next to his room so he only had to peek out and grab a juice box when he wanted something to drink,” she says. “But that’s not helpful in the long run.”

On the other hand, it can be equally harmful to ignore or dismiss anxious thoughts since, “the more you try to avoid or accommodate anxiety, the stronger it gets,” Dr. Gerber says.

One relatively new approach to helping kids with GAD or other kinds of anxiety involves a therapist working with parents alone — not directly with the children. It’s called Supportive Parenting for Anxious Child Emotions , or SPACE, and it teaches parents how to change their own behavior in order to help their child overcome anxiety.

If parents have anxiety themselves, it can also help for them to get support or treatment, she adds. In turn, they’ll be better equipped to help their child with it as well.

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Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment.

July 2006, Vol. XXIII, No. 8

Cognitive-Behavioral Therapy for Adolescent Depression

Developing an Effective Treatment Protocol

Family Therapy in the Treatment of Depression

NAMI Programs Educate Families of Mentally Ill

From Prevention to Preemption: A Paradigm Shift in Psychiatry

More > >

Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment. 1-3 Family CBT (FCBT) has consistently yielded a high proportion of treatment responders (more than 70%) and in some studies has outperformed CBT programs with little family involvement. 3 This article presents the rationale supporting FCBT, provides a case study illustrating FCBT techniques, and summarizes the findings of a recent clinical trial.

RATIONALE SUPPORTING FCBT

FCBT for children’s anxiety disorders draws on effective cognitive-behavioral techniques 4 and supplements these with targeted family interventions . A good description of fundamental CBT techniques was published in 2003. 5 CBT for children’s anxiety disorders consists of 2 phases: skills training, and application and practice. During the skills training phase, children are taught techniques for reappraisal of feared situations, relaxation, and self-reward. In the application and practice phase, a hierarchy is created in which feared situations are ordered from least to most distressing. Children work their way up the hierarchy and are rewarded as they attempt increasingly fearful activities.

Seven studies have compared versions of FCBT with versions of child-focused CBT (CCBT) with little family involvement for children presenting with anxiety disorders . 3 Five of the studies have reported some outcome measures favoring FCBT over CCBT at the posttreatment assessment, whereas no outcome measures have favored CCBT over FCBT. In contrast, there were no differences found between the FCBT and CCBT programs studied, 6,7 and some longer-term outcome studies have suggested that differences between FCBT and CCBT lessen over the course of time. Nonetheless, the extant evidence suggests that there may be some advantage of the FCBT paradigm, particularly with regard to immediate effects.

Most FCBT programs have not focused on the specific parenting practices that are hypothesized to contribute to the development and maintenance of anxiety in children. In comparison, the FCBT program Building Confidence (J.J. Wood et al, unpublished manual, 2006) was developed by drawing on basic research in parent-child interaction patterns in families of children with anxiety disorders, 8,9 with the goal of enhancing treatment effectiveness. These studies suggest that high levels of parental intrusiveness and a lack of parent-granted autonomy are linked with anxiety disorders in children.

Parents who act intrusively tend to take over tasks that children are (or could be) doing independently and impose an immature level of functioning on their children. Among schoolaged children, parental intrusiveness can manifest in at least 3 domains: unnecessary assistance with children’s daily routines (eg, dressing), infantilizing behavior (eg, using baby words, excessive physical affection), and invasions of privacy (eg, parents opening doors without knocking). 10 Parents who act intrusively are posited to interfere with the process of habituation (fear reduction) by preventing children from actually confronting feared but benign stimuli. 9,11 Conversely, parents who grant appropriate levels of autonomy may enhance children’s feelings of mastery and self-efficacy, 12 and thus contribute to the regulation of anxiety.

The Building Confidence FCBT manual goes beyond previous CBT programs by directly intervening with parental intrusiveness and parentgranted autonomy. 10 The Building Confidence program includes individual sessions with the child and complementary parent-training sessions. These parent-training sessions emphasize:

• Giving choices when children are indecisive (rather than making choices for them).
• Allowing children to struggle and learn by trial and error rather than taking over tasks for them.
• Labeling and accepting children’s emotional responses (rather than criticizing them).
• Promoting children’s acquisition of novel self-help skills.

An incentive system is also taught to parents to encourage their children’s courageous behavior. A typical FCBT session begins with a 20-minute individual meeting with the child to conduct skills training or application/practice. Skills are reviewed less thoroughly with the child than in CCBT, permitting time for parent-training (20 minutes) and conjoint parent-child meetings (10 minutes). The following case describes a child with separation anxiety, but the issues it raises are also applicable to other types of anxiety disorders.

Ben is an 11-year-old boy living with his single mother in a semirural area of California. They share a small apartment with another single mother and her school-aged son. Ben’s mother works from home and their income is below the poverty line.

Ben is a slender boy with a friendly smile who is extremely nervous about being away from his mother, a behavior that meets the criteria for separation anxiety disorder. He has missed 20 days of school in the 2 months before intake because of reluctance to be away from home, has left school early 5 times because he felt “sick,” and frequently goes to the nurse’s office in school. His pediatrician has found no medical problem that would explain these difficulties.

Ben sleeps in his mother’s bed every night. He is distressed by worries about his mother being in a car accident while he is away from her, a concern not based on previous experience. Ben has avoided playdates, team sports, and afterschool activities because of separation anxiety, causing his mother to worry about his social development. Ben is exceptionally well-behaved and polite, and he has a precocious sense of humor. He noticeably perked up when interacting with male clinicians, flopping around the therapy room in mock slapstick routines or rushing to initiate conversation about topics he thought would be of interest.

There are numerous signs of intrusive parenting: Ben’s mother encourages his sleeping with her; she showers with him and washes his hair (an atypical scenario for an 11- year-old), she dresses and undresses him, and grooms his hair (which tangles easily and is difficult to manage) on a daily basis. Despite receiving assistance from his mother during these routines, Ben is actually capable of self-care in each of these areas. Ben also often sits on his mother’s lap, both he and his mother assert that all of these interactions help him feel less anxious.

FCBT USING THE BUILDING CONFIDENCE PROGRAM

The case study illustrates a typical pre-sentation of a child with separation anxiety disorder. 10 Commonly, as in Ben’s case, sexual abuse is screened for and ruled out; nonetheless, the intrusive interactions in question are developmentally inappropriate. In Ben’s case, the interactions appeared to be unintentionally reinforcing to his mother, since she indicated that she enjoyed being able to “be there for him and comfort him.”

Paradoxically, such comforting seems to support Ben’s separation anxiety rather than eradicate it. He feels dependent on his mother’s comforting for the regulation of his anxiety, and when he is away from her he finds it challenging to cope with the anxiety he experiences. Child psychiatrists and psychologists do not always screen for these kinds of intrusive parenting behaviors and, therefore, may be unaware of the role such behaviors play in the maintenance of anxiety disorders in children.

Skills training and focus on autonomy-granting

The first 4 sessions of FCBT focus on teaching core CBT skills, such as positive self-talk, and core parenting skills that can facilitate a child’s independence and self-confidence. Ben was exceptionally motivated, thrived on praise from his therapist, and made rapid progress in learning CBT skills. Coping skills that were emphasized included challenging Ben’s worries about his mother’s safety (eg, “My mom has never been in a car accident before, how likely would it be?”). However, Ben’s separation anxiety symptoms were slow to remit early in treatment. A major focus of parent training was increasing parentgranted autonomy and reducing intrusiveness. In talking with Ben’s mother, it was noted that children feel more confident when they do things for themselves that others have previously done for them and that this confidence can lead to courageous behavior.

Like many parents, Ben’s mother seemed to be caught between agreement (“He is very clingy,” she would acknowledge) and doubt (“He is only 11; can’t he still be a little boy?”). She emphasized that Ben’s clingy behaviors were not burdensome to her. To address her ambivalence, several techniques were employed:

• Empathizing with her desire to keep Ben close to her.
• Warning her that without him becoming a bit more independent, Ben’s maladaptive anxiety-related behaviors were likely to get worse.
• Offering a plan of action that emphasized gradual changes in parent-child interaction.

Parent communication skills, such as giving choices, as described above, were taught to Ben’s mother to support his development of autonomous behaviors. (Note that all parent-training activities in FCBT are directly related to 1 of 2 goals: altering the targeted parent-child interaction patterns or enhancing the child’s application/practice of CBT skills.)

Initial steps in increasing autonomygranting and reducing intrusiveness were selected by Ben, who noted that showering on his own and dressing himself would not be a problem as long as his mother was somewhere in the house. In a family meeting, Ben presented this to his mother and a plan was made to try it out. At the following session, Ben was praised for his followthrough. The therapist assessed the progress of these independent skills during each session, and Ben would flash an enormous smile, proudly affirming his mastery of the self-help tasks. Hair-brushing was added to the list, and when his mother could not tolerate his “lack of skill,” she simply gave him a shorter haircut that was largely maintenance- free-an excellent solution that supported Ben’s autonomy.

Ben’s mother-while not undermining these changes-did express sadness about his emerging independence. This reaction was normalized by the therapist (“All parents feel this way as their children become more mature”). Frequent reminders of the treatment rationale, and particularly the important role parents play in children’s anxiety reduction (by supporting their autonomy), were helpful in maintaining the mother-therapist alliance, as well as the changes in family routines that had been achieved.

Skills application and practice with parent support

A key tenet of FCBT is that early increases in parent-granted autonomy and independent child behaviors in sessions 1 through 4 pave the way for (a) increased self-confidence in the child, which facilitates the child’s engagement in facing feared situations in sessions 5 through 16 and (b) parental adoption of communication techniques (eg, giving choices) that enhance the effectiveness of the application and practice phase of CBT.

Ben’s first task in the application/practice phase was returning to school, and the timing of this coincided closely with his upsurge in self-confidence following the independent behavior sessions. Typical CBT techniques for addressing school refusal were employed, 13 and Ben stayed at school for longer and longer periods each day. Though predictably nervous, he tried his hardest, focused on challenging his fearful thoughts about his mother’s safety, and successfully ignored his anxious feelings (which were labeled “false alarms”). Incentives offered by his mother (eg, earning television time) also helped promote his adherence to the school-return plan.

Ben returned to school full time by session 10, evidencing habituation and a humorous “blas” attitude about his success. It is worth additional emphasis that the rapidity and ease with which full school return was accomplished was facilitated by Ben’s early self-confidence in the independent skills exercises and by his mother’s use of parenting skills to support his autonomy, both of which are FCBT-specific strategies.

Reducing cosleeping-a key goal in separation anxiety treatment-proved to be a formidable challenge. Ben agreed in principle by session 8 to sleep in his own bed on a nightly basis, but his mother was noncommittal. Ben’s anxiety was moderately high about sleeping independently even after the many successes he had achieved by midtreatment. Without his complete investment in this task, and with his mother’s reticence about changing their routine, treatment progress plateaued for several sessions (Ben’s mother said they had simply forgotten to have him sleep by himself).

Two shifts in the therapist’s approach proved critical. First, to increase the mother’s motivation, it was noted to her that full remission of separation anxiety rarely occurs unless children sleep on their own (which is true, in our clinical experience) and that excessive anxiety could ultimately interfere with Ben’s social and intellectual development. Second, to increase Ben’s motivation, a checklist was made of a number of highly feared tasks that when completed would lead to what he considered a large reward (a video his mother agreed to purchase for him). This checklist included Ben sleeping independently for 4 weeks in a row, inviting children from school over at least 4 times, and joining an after-school activity (choices were given).

Of course, Ben was given help in applying CBT skills in preparation for these activities. It was thought that by appealing to both Ben and his mother, chances for success would be doubled compared with relying on the solitary (and wavering) motivation of either of them alone.

This multifaceted approach proved effective. Ben’s mother was sufficiently persuaded by the therapist’s logic to permit a trial of the sleeping plan, while Ben was quite invested in his checklist incentive program and began sleeping independently. Within 2 weeks, Ben’s ratings on a 0-to-10 anxiety scale indicated that he felt no anxiety when sleeping by himself (again, reflecting habituation to a feared-but benign- situation). Simultaneously, he initiated playdates with a neighborhood boy that soon became reciprocal, and joined an after-school music program that he enjoyed. Ben’s mother was pleased with these accomplishments and began to praise the therapy program, including its emphasis on Ben’s independence. She voiced no further reservations about the new sleeping arrangements.

While still exhibiting a shy, eagerto- please disposition, Ben had no core anxiety disorder symptoms by session 16 when he was interviewed by an independent evaluator (using a structured diagnostic interview). Treatment gains were maintained at a 1-year follow-up interview

FINDINGS FROM A RECENT CLINICAL TRIAL

In a recent clinical trial, the Building Confidence FCBT program was compared with traditional CCBT with minimal family involvement. 3 Forty children with anxiety disorders (aged 6 through 13 years) were randomly assigned to FCBT or CCBT. Anxiety disorders (separation anxiety disorder, social phobia, and/or generalized anxiety disorder) were confirmed by an independent evaluator using a structured diagnostic interview. The 2 treatment conditions were matched for therapist contact time (12 to16 therapy sessions lasting 60 to 80 minutes each). Outcome measures included independent evaluators’ diagnoses, severity ratings for each diagnosis on the Clinician’s Rating Scale, 14 and improvement ratings on the Clinical Global Impressions (CGI) scale; child-reports on the Multidimensional Anxiety Scale for Children (MASC) 15 ; and parent reports on the MASC.

Overall, results favored FCBT over CCBT, highlights included:

• 79% of children in FCBT met CGI criteria for good treatment response, compared with only 26% of children in CCBT.
• Children in FCBT had greater improvement on independent evaluators’ ratings on the Clinician’s Rating Scale than children in CCBT.
• Parent reports of child anxiety on the MASC-but not children’s selfreports- were lower in FCBT than CCBT at posttreatment.

Although both treatment groups showed statistically significant improvement on all outcome measures, FCBT provided additional benefit over and above CCBT on most indices of improvement.

It should be noted that FCBT appears to be equally effective for children with primary diagnoses of separation anxiety disorder, social phobia, and generalized anxiety disorder. Although the case study presented above illustrates how FCBT can address separation anxiety, parental involvement is also beneficial for the treatment of the other 2 primary child anxiety disorder diagnoses. For example, parental intrusiveness is often seen in cases of children with social anxiety. Parents may offer excessive comfort when children are fearful in social situations and take over social tasks (eg, by speaking for their children) that children could handle independently. Variations of the FCBT techniques described above have proved helpful in addressing such family interaction patterns.

FCBT involves a complex interplay of cognitive-behavioral techniques and family restructuring, drawing on the combined (and sometimes complementary) resources and motivations of children and their parents. While CCBT is quite effective by itself, FCBT can lead to even greater improvements in anxiety, at least in the short term. 3 Therefore, it may be beneficial for clinicians to assess for parental intrusive-ness and autonomy-granting in cases of school-aged children with anxiety disorder and consider the use of a structured FCBT protocol that explicitly addresses such family dynamics when they are present.

Disclosures:

Dr Wood is an assistant professor of psychological studies in education in the department of education at the University of California, Los Angeles. His research focuses on the psychopathology of childhood anxiety, with an emphasis on randomized, controlled trials of cognitive- behavioral therapy interventions. The writing of this paper was supported, in part, by a grant from NIMH awarded to Dr Wood (MH075806). He reports that he has no conflicts of interest with the subject matter of this article.

References:

1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342. 2. Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consut Clin Psychol. 1998;66:893-905. 3. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006; 45:314-321. 4. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994;62:100-110. 5. Silverman WK. Using CBT in the treatment of social phobia, separation anxiety and GAD. Psychiatr Times. September 2003; Vol 20. 6. Nauta MH, Scholing A, Emmelkamp PM, Minderaa RB. Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of a cognitive parent training. J Am Acad Child Adolesc Psychiatry. 2003;42:1270-1278. 7. Spence SH, Donovan C, Brechman-Toussaint M. The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitivebehavioural intervention, with and without parental involvement. J Child Psychol Psychiatry. 2000;41: 713-726. 8. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39:1411-1427. 9. Rapee RM. The development of generalized anxiety. In:Vasey MW, Dadds MR, eds. The Developmental Psychopathology of Anxiety. New York: Oxford University Press; 2001. 10. Wood JJ. Parental intrusiveness and children’s separation anxiety in a clinical sample. Child Psychiatry Hum Dev. In press. 11. Fox NA, Henderson HA, Marshall PJ, et al. Behavioral inhibition: linking biology and behavior within a developmental framework. Annu Rev Psychol. 2005;56:235-262. 12. Chorpita BF, Barlow DH. The development of anxiety: the role of control in the early environment. Psychol Bull. 1998;124:3-21. 13. Kearney CA, Hugelshofer DS. Systemic and clinical strategies for preventing school refusal behavior in youth. J Cog Psychother. 2000;14:51-65. 14. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: Graywind; 1996. 15. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.

Evidence-based References

Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006;45:314-321

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Home / Parenting, Kids & Teens / Could my child’s social challenges actually be signs of social anxiety disorder?

Could my child’s social challenges actually be signs of social anxiety disorder?

An excerpt from Anxiety Coach

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Anxiety Coach by Mayo Clinic child psychologist Stephen P. Whiteside, Ph.D, L.P, takes Mayo Clinic’s safe, rapid, effective Exposure Therapy program for children and teens suffering from anxiety disorders, OCD and phobias, and adapts it from a supervised clinical setting to the family home in an easy to follow self help guide for parents and kids. In the following excerpt from Anxiety Coach , Stephen Whiteside helps parents figure out if their child’s social challenges are actually signs of social anxiety disorder, what sets off social anxiety, why a child avoids triggering situations and finally presents a simple case study of a 16 year old girl with social anxiety disorder, who went on to be successfully treated with Exposure therapy.     

What is social anxiety disorder ?

The term social anxiety disorder fits when children are overly nervous about interacting with other people, particularly peers. Kids with social anxiety are afraid they will make mistakes when talking or will say or do something that could lead other people to think of them negatively. Feeling nervous leads kids to avoid situations that involve talking with or hanging out with or even being around other kids. When children with social anxiety disorder consistently avoid social situations, it means they miss out on fun activities, like sports, or don’t do things they need to do, like give a class presentation. Over time, missing out on these important activities can cause other problems. Social anxiety disorder is one of the most common reasons families come to our clinic.

How do we know it’s social anxiety disorder?

Social anxiety disorder is different from typical shyness in the degree of anxiety that kids experience and how much their fears cause problems. There is nothing wrong with being shy or introverted; I myself was pretty shy as a child. Being nervous giving presentations at school or starting a new activity is also a very normal, common experience. As I mentioned earlier, it’s important not to unnecessarily label your child’s behavior as a problem. If they are content with the way they are living their life and they are doing the school and social activities they need to, that’s a solid sign that all is well. However, when fears of embarrassment are so upsetting that  they get in the way of living everyday life, that’s when we call it social anxiety disorder and recommend treatment. There are times in our clinic when kids and parents disagree on whether social anxiety is a problem. This usually happens in two scenarios. Since many social interactions for kids occur in school, without parents there to witness their child’s difficulties, parents have only the impression they get from seeing their child function in the family setting, whether that’s at home or in public. In these cases, parents may not realize how much their teens or kids are struggling socially. Other times, it’s the reverse, and kids are so upset by their social difficulties that they deny they are nervous and instead say they are simply not interested in spending time with other kids, and what is wrong with that conscious choice, if they are making it? In that and similar kinds of cases, we need to focus on the three jobs we expect from kids and teens—being successful in school, with friends, and at home—and if there are problems in those areas, we can explore how social anxiety might be getting in the way. In addition to situations and activities, for some kids social anxiety is set off by memories of awkward social situations or physical feelings of anxiety or embarrassment, like blushing or sweating, which lead to the same withdrawal and avoidance as social anxiety that relates to real-time, everyday scenarios.

What sets off my child’s social anxiety?

Social anxiety is typically set off by things in the world around us, most often situations in which kids need to talk to their peers or other people or when they may be observed by others. There are many different types of social situations and not all will give your child feelings of anxiety. Some children get more nervous in performance situations— reading aloud in class, acting in a school play, singing in a school musical, answering a question in class, competing in a basketball game, playing in a school concert, or giving a presentation in class. Others might get more nervous in unstructured social situations, like initiating conversations, meeting other kids at the start of a new school year, joining a club, finding people to sit with during lunch, or making small talk in the hallways between classes. And then there are kids whose anxiety is set off by talking to adults, especially in public situations such as the school principal, a teacher, or a sports coach. These children may also be nervous to order food at restaurants, ask questions of store clerks, or check out with you at the grocery store. Sometimes children feel nervous simply being in public where people may be watching and observing them. For many kids with social anxiety, all of the above may set off their anxiety.

Expectations that make social situations scary                                      

Once you’ve identified the situations that set off your child’s anxiety, the next thing to do is pinpoint the expectations that cause your child to feel nervous in these situations when most of their peers enjoy them or feel only somewhat uncomfortable. As we have learned, there are two main expectations that drive fear and worry— something bad will happen and I won’t be able to handle this —both apply to kids with social anxiety. A core component of social anxiety is the fear of being judged negatively. However, the type of feared judgment often differs based on the situation in which kids feel anxious. Kids who get nervous speaking in performance situations may have expectations that they will make mistakes, perform poorly, and be judged as not good enough, smart enough, or talented enough. Kids who are more nervous about talking to peers may be more afraid that they will do something embarrassing and everyone will think they’re uncool or unlikable. And when kids are nervous around authority figures they are typically concerned about getting in trouble, being a burden, or irritating others. For many children with social anxiety, expectations can occur in any combination of the above. Despite the importance of expecting negative judgment in social anxiety, it’s important to note that some kids don’t describe these specific worries. Younger kids especially are more likely to simply say that talking to others is scary and they don’t know why. Teens may add that they know it’s unlikely that people will laugh at them or be mean but that they still feel nervous. If this is the case, you might describe the child’s expectation as believing they can’t handle talking to people or they have to avoid being around people to feel okay.                                                   

Avoidance of social situations

Next, we need to identify what avoidance strategies your child uses to stay away from the situations they fear and in doing so, miss out on the opportunity to learn that these situations are not as bad as they expect them to be. The most common form of avoidance for kids with social anxiety disorder is partial physical avoidance, which is when kids can’t completely avoid a situation but try to avoid as much of it as possible when they are in the midst of it. For example, these kids can’t avoid going to class, but when in class, they are careful never to raise their hand to answer a question asked by a teacher. Or because of anxiety around playing on the school football team, a teen might arrive at practice at the last minute and rush home quickly afterward to avoid the banter and socializing among teammates in the locker room. Partial avoidance due to social anxiety can also include a child keeping their head down while walking in the hallways between classes at school, avoiding eye contact to make sure no one talks to them, or purposefully reading a book before class to put up a wall against being greeted by fellow classmates. As many parents of socially anxious children know, full avoidance of anxiety-provoking activities can also occur. Complete avoidance involves not signing up for sports, clubs, and other extracurricular activities. Or not attending school dances or sporting events. Or eating lunch in the library. It may grow to include staying home from school on days there is a presentation due or even transitioning to online school or homeschooling. Kids with social anxiety may also often rely on others to help avoid feared social interactions. As we saw earlier, parents may be asked to order food in restaurants or communicate with teachers.

Social anxiety disorder, a case study

Meet 16-year-old Maria, a smart, likable teenager and a successful figure skater. She and her parents agreed that she had always been shy, but it hadn’t been a problem because she’d maintained a core group of friends since kindergarten. In restaurants, she’d appear nervous, and her parents would order for her, but they weren’t overly concerned about it. None of this was a problem until she entered middle school. With that transition, she began to struggle. Her core friends connected with new faces and added new friends, while Maria stayed on the sidelines, feeling shy. She felt even more nervous in class when she didn’t yet know many of the other students and, with seven different classes a day, there wasn’t much of a chance to get to know her teachers. In this new environment, she came to dread presentations, yet was too nervous to ask for help. Under pressure across the board, some of her grades began to slip. When Maria began to complain that she felt too sick to go to school on days she had a class where there was always a lot of student participation, her parents brought her in to Mayo Clinic for help. During the initial assessment, Maria readily acknowledged that in social situations she was afraid she would say the wrong thing and look ridiculous in front of other kids who all seemed to be calm, outgoing, and happy to make new friends and expand their social circle. She had always felt comfortable with figure skating because so much of it involved working on her own without having to make conversation with the other skaters. However, now that they were getting older and spending more time chit chatting before and after practice, she was struggling with these interactions and feeling awkward. What she feared most was doing something foolish that would lead her peers to laugh at her and, as a result, see no value in being friends with her. Although she outright avoided some school activities and relied on her parents to order for her at restaurants, most of her avoidance strategies involved finding ways to dodge direct conversation when at school or during activities by looking busy, avoiding eye contact, or leaving early. It had reached a point where she felt left out and was considering quitting. After our clinical assessment, a diagnosis of social anxiety disorder was agreed upon and she went on to be rapidly and successfully treated with Exposure therapy. 

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Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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Is anxiety rising in children and if so, why?

Evidence points to more children today feeling anxious than a few years ago, with a complicated picture emerging encompassing everything from the pandemic to social media

By Bethan Ackerley

3 April 2024

Childhood anxiety is on the rise for a multitude of reasons

Giuseppe Di Bella/Millennium Images, UK

CHILDHOOD can be a time of great anxiety. It is when we learn how to make friends and cope when those friendships go sour, when we first feel the pressures of school work and exams, and when the difficulties of puberty kick in.

But recent research suggests that childhood anxiety is on the rise, with more children feeling anxious today than even just a few years ago. As researchers start to investigate why this might be, a complicated picture is emerging, encompassing everything from the covid-19 pandemic to social media. Thankfully, there are ways to help children to ensure the potential long-term effects are limited.

Why spending time near water gives us a powerful mental health boost

Evidence for high levels of anxiety in children comes from an analysis of 29 studies that were published between 2020 and 2021 that included 80,000 young people from around the world. It found that 20.5 per cent of children had clinically significant anxiety symptoms, with girls and older adolescents particularly affected.

Of course, 2020 and 2021 were defined by the covid-19 pandemic, when many people of all ages felt increased anxiety (see “ Anxiety really has increased over the past 10 years – but why? “). However, prior to the pandemic the generally accepted prevalence figure for young people was 11.6 per cent , from a study that surveyed 37 per cent of Finnish adolescents aged 14 to 18 in 2015. Signs that anxiety diagnoses were rising in younger people even earlier come…

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Screen for Child Anxiety Related Disorders (SCARED)

• Open access
• Published: 02 April 2024

Psychometric properties of the GAD-7 (General Anxiety Disorder-7): a cross-sectional study of the Peruvian general population

• David Villarreal-Zegarra   ORCID: orcid.org/0000-0002-2222-4764 1 , 4 ,
• Rubi Paredes-Angeles   ORCID: orcid.org/0000-0003-3669-4932 4 ,
• Nikol Mayo-Puchoc   ORCID: orcid.org/0000-0002-6182-7605 4 ,
• Enoc Arenas-Minaya   ORCID: orcid.org/0000-0001-9577-6212 5 ,
• Jeff Huarcaya-Victoria   ORCID: orcid.org/0000-0003-4525-9545 2 &
• Anthony Copez-Lonzoy   ORCID: orcid.org/0000-0003-4761-4272 3 , 4  

BMC Psychology volume  12 , Article number:  183 ( 2024 ) Cite this article

Metrics details

Anxiety disorders are among the main mental health problems worldwide and are considered one of the most disabling conditions. Therefore, it is essential to have measurement tools that can be used to screen for anxiety symptoms in the general population and thus identify potential cases of people with anxiety symptoms and provide them with timely care. Our aim was to evaluate the psychometric properties of the General Anxiety Disorder-7 scale (GAD-7) in the Peruvian population.

Our study was a cross-sectional study. The sample included people aged 12 to 65 years in Peru. Confirmatory factor analysis, analysis of measurement invariance, convergent validity with the Patient Health Questionnaire-9 (PHQ-9) and internal consistency analysis were performed.

In total, 4431 participants were included. The one-factor model showed the best fit (CFI = 0.994; TLI = 0.991; RMSEA = 0.068; WRMR = 1.567). The GAD-7 score showed measurement invariance between men and women and between age groups (adults vs. adolescents) (ΔCFI < 0.01). The internal consistency of the one-factor model was satisfactory (ω = 0.90, α = 0.93). The relationship between depressive symptoms (PHQ-9) and anxiety symptoms (GAD-7) presented a moderate correlation ( r  = 0.77).

Conclusions

Our study concluded that the GAD-7 score shows evidence of validity and reliability for the one-factor model. Furthermore, because the GAD-7 score is invariant, comparisons can be made between groups (i.e., by sex and age group). Finally, we recommend the use of the GAD-7 for the general population in the Peruvian context.

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Introduction

Anxiety disorders (ADs) are among the main mental health problems worldwide and are considered among the most disabling mental health problems; they were among the 25 leading causes of mental health burden worldwide in 2019 [ 1 ]. The number of ADs has been increasing; in 2015, the estimated incidence of anxiety disorders worldwide was 3.6% (264 million), with a greater proportion of women [ 2 ]. The region of the Americas represented 21% (57.22 million) of all cases, and in Peru, 5.7% of people had AD [ 2 ]. In 2020, before COVID-19, the estimated global incidence of AD reached 298 million, and after the pandemic, the incidence increased by 25.6%, reaching an estimated global prevalence of 374 million. This increase was also greater for women (27.9%; 51.8 million) than for men (21.7%; 24.4 million). In addition, these percentages vary according to country, with an increase greater than 36.4% in AD occurring in Peru [ 3 ].

In this sense, it is necessary to have instruments with good psychometric properties that are brief and screening for easy, fast, and timely risk assessment of this disorder in the population. The most common instruments for measuring anxious symptoms include the Generalized Anxiety Disorders-7 (GAD-7); Beck Anxiety Inventory (21 items) [ 4 ]; the Hospital Anxiety and Depression Scale-Anxiety Subscale (7 items) [ 5 ]; the Depression, Anxiety and Stress Scale-Anxiety Subscale (7 items) [ 6 ]; State-Trait Anxiety Inventory (20 items) [ 7 ]; and the Zung Self-rating Anxiety Scale (20 items) [ 8 ]. These instruments are most commonly used with adults and adolescents, as older adults have different criteria for anxiety [ 9 ].

The GAD-7 is one of the instruments with the fewest number of items and was created according to diagnostic criteria from the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), to detect generalized anxiety disorders [ 10 ]. Additionally, it is widely used in the clinical field [ 11 , 12 ], demonstrating good performance and adequate diagnostic accuracy [ 11 ]. Similarly, this instrument has shown good results in different populations and situations, such as in university students [ 13 , 14 ], adolescents [ 15 ], older adults [ 16 ], and health workers [ 17 ]; in virtual evaluations [ 18 ]; and because it is used for screening, it is also useful for obtaining prevalence estimates in the general population [ 19 , 20 ].

Despite being widely used, the GAD-7 has some heterogeneity in terms of its dimensionality. Most studies agree that the original one-factor model works well [ 16 , 21 , 22 , 23 ]; however, some studies report some modifications to this factorial structure, considering errors correlated between somatic items [ 24 , 25 ]. Other studies have considered a two-factor model, distinguishing cognitive-emotional aspects from somatic ones [ 26 , 27 ], and another study has suggested using a second-order model, taking cognitive-emotional and somatic elements as first-order factors [ 28 ]. However, to date, there is no consensus on the most appropriate factor structure for the GAD-7, but the one-factor model is the most widely used [ 35 , 36 ].

Another important property is measurement invariance, understood as the equivalence (in psychometric terms) of a construct across groups, which has the same meaning as those groups and is a prerequisite for comparing group means [ 29 ]. This property is not always reported, and the results of measurement invariance studies of GAD-7 scores according to age and sex have some discrepancies. Some studies have shown that invariance is achieved by sex and age [ 26 ], while in other studies, invariance is violated [ 30 ]; therefore, if this property is not verified in a population, comparisons between sex or age groups can lead to biased results and interpretations. Despite the available evidence, there are gaps in the knowledge of which variables GAD-7 is invariant and which are not. Therefore, this is still an open area of research.

Additional evidence of validity reported for the GAD-7 is its relationship with other variables, which are strongly related to depressive symptoms and are generally measured by the PHQ-9 [ 24 , 28 , 31 ]. This relationship is consistent with what is expected between depressive and anxiety disorders, both of which are considered common mental disorders due to their high prevalence and comorbidity [ 2 ].

The GAD-7 is a widely researched and useful tool for detecting potential cases of anxiety symptoms. Despite its usefulness, evidence regarding its factor structure and its invariance between groups is mixed. This highlights the need for further research to clarify these aspects. Given the importance of confirming adequate psychometric properties before using an instrument in a specific population, our study aims to: (1) Analyze the factorial structure of the original GAD-7 in the Peruvian population; (2) Evaluate GAD-7 measurement invariance based on sex and age; (3) Report the relationship with other variables (depressive symptoms); and (4) Estimate the reliability of the GAD-7. Our central hypotheses are that the GAD-7 has a strong factor structure, is invariant across gender and age groups, has a strong relationship with depressive symptoms, and has optimal levels of reliability.

Study design

Secondary data from six studies were obtained before and during the COVID-19 pandemic, and a cross-sectional design was used to evaluate the psychometric properties and validity of the GAD-7 in teenagers and adults in Lima, Peru.

Peru is a middle-income Latin American country that has had several problems in its health system since before the outbreak of COVID-19. The Peruvian government decreed of a state of sanitary emergency (March 16, 2020) to mitigate the spread of the infection, and a suppressive strategy was adopted (social isolation or quarantine). Moreover, the suspension of activities such as economic, academic, transport, and recreational activities was stipulated, and only essential activities related to the supply of products and services for public health were maintained [ 32 , 33 ].

Evidence indicates that the mental health impacts (e.g., anxiety, depression, posttraumatic stress) caused by strict health measures in low-income and middle-income countries have a significant mental impact, which contributes to a slow recovery toward normality [ 34 ].

Participants

The following six datasets were used to analyze the data of patients who met the inclusion criteria: (1) aged 12 years to 65 years. (2) Patients had complete data on the GAD-7 score, sex, and age. (3) Participants must have agreed to participate in the study first after providing informed consent. For those under 18 years of age, only those participants whose parents provided consent for their children to participate were considered (informed consent). We excluded participants with implausible data (i.e., age > 99 years). Nonprobabilistic sampling was performed for all the datasets.

Measurement

Anxiety symptoms.

The General Anxiety Disorder-7 scale (GAD-7) is a 7-item self-report Likert scale that was developed to assess the severity of anxiety disorders based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). This self-report measures the indicators of anxiety symptomatology in the last 2 weeks. Each item is rated on a 4-point Likert-type scale (0 = not at all; 1 = several days; 2 = more than half the day; 3 = nearly every day) [ 10 ]. To identify possible cases of general anxiety disorder (GAD), some studies considered using a cutoff range of 10 points because this cutoff provides a high balance between sensitivity and specificity [ 35 , 36 ]. We use the Spanish version of GAD-7 by Soto-Balbuena and collaborators [ 22 ].

Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9) is a 9-item Likert scale developed to measure the severity of depressive symptoms; this scale was designed from the nine diagnostic criteria from the DSM-IV. The instrument reports the indicators of depressive symptomatology over the past 2 weeks. Its response options were 4-point Likert-type scales (0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day) [ 37 ]. According to other studies, a standard cutoff score of 10 or above can be used for screening to detect moderate depressive symptoms [ 37 , 38 ]. The PHQ-9 has been validated in a Peruvian population sample, where it presented optimal validity and reliability values [ 39 ].

Participants were recruited through an online Google Forms form, which was distributed to potential participants through networking via instant messaging applications such as WhatsApp and Telegram, as well as social media platforms such as Facebook and Instagram. Participants received no economic incentives or rewards. Participation was voluntary, and they accepted informed consent before the evaluation process began.

Statistical methods

All the analyses were performed in RStudio [ 40 ] using the packages lavaan [ 41 ], semTool [ 42 ] and semPlot [ 43 ].

Descriptive analysis

A descriptive analysis of participant characteristics was also conducted (mean, standard deviation, percentage, and frequency). The prevalence of anxious and depressive symptoms was based on the cut-off of 10 points or more for the GAD-7 and PHQ-9, respectively. In addition, we performed a descriptive analysis of the items using mean, standard deviation, skewness, and kurtosis.

Confirming factor analysis

We used one-factor, two-factor, and second-order factor models to assess the factorial structure of GAD-7 scores. All the models use the weighted least squares means and variance adjusted (WLSMV) estimator because of its ability to provide a good option for modeling categorical or ordered data [ 44 , 45 ]. Additionally, a polychoric correlation matrix was calculated. Therefore, to evaluate the model fit, the weighted root mean square residual (WRMR), the comparative fit index (CFI), and the root mean square error of approximation (RMSEA) along with 90% confidence intervals (90% CIs) were used. A reasonably good fit is recommended following the following criteria: (a) WRMR < 1 or below; (b) RMSEA < 0.08 or below; and (c) CFI and TLI > 0.95 or above [ 46 , 47 ]. This analysis was performed to determine the best factor structure of the GAD-7.

Invariance between groups

Testing for measurement invariance involves testing a series of hierarchically nested models to assess whether the instrument is stable between two or more groups; thus, comparisons can be made between them [ 48 ]. Comparisons were made between sex groups (male and female) and ages (adolescents and adults). To compare models with more restrictions against models with fewer restrictions, we used ΔCFI and ΔRMSEA as variants of the comparative fit index and the root means the square error of approximation, respectively. Thus, ΔCFI values < 0.01 and ΔRMSEA values < 0.015 provide evidence for measurement invariance [ 29 , 49 ]. In addition, we assessed other fit indices, such as the CFI and RMSEA, along with 90% confidence intervals. This analysis was performed to determine whether the GAD-7 showed measurement invariance between groups, allowing comparisons to be made between these groups.

Convergent validity

To examine convergent validity, the GAD-7 and the PHQ-9 total scores were correlated. Due to its concordance with other samples, the GAD-7 score was hypothesized to be strongly correlated with depression indicators (PHQ-9) [ 24 , 28 , 31 ]. This correlation was determined by Pearson’s r (r). A large ( r  > 0.70), moderate ( r  > 0.50) or small ( r  > 0.30) ratio was determined based on the size of the correlation coefficient [ 50 ].

Reliability

Internal consistency analyses were performed using two coefficients: the ordinal alpha (α) and categorical omega (ω) coefficients. Both are acceptably reliable when the coefficient values are greater than 0.80 [ 50 ]. In addition, we performed a test item correlation analysis.

Ethics aspects

The institutional research ethics committee of the Instituto Peruano de Orientación Psicológica approved the study protocol.

Characteristics of the participants

Initially, we found 5048 records in the different datasets, and we eliminated 617 records after applying the inclusion criteria (12.2%). Therefore, the study included a total sample of 4431 participants. The sample consisted of 1929 men (43.5%) and 2502 women (56.5%), and the ages ranged from 11 to 65 years (M = 28.9 years; SD = 12.8). Furthermore, 3581 were adults (80.8%), and 850 were adolescents (19.2%). Additionally, 3653 patients were evaluated during the COVID-19 pandemic (82.4%), and 778 were evaluated before the pandemic (17.6%). In terms of prevalence, we found that 20.8% of participants presented anxious symptoms ( n  = 922) and that 29.5% had depressive symptoms ( n  = 1307). In addition, the raw scores of the GAD-7 and their measures of skewness and kurtosis are presented (see Table  1 ).

Confirmatory factor analysis

Our study evaluated different factor models based on previous studies. Based on this, we determined that all the models evaluated achieved optimal goodness-of-fit indices (see Table  2 ). The model with two correlated factors exhibited a very high correlation (Φ > 0.90). Therefore, we believe that both factors overlap, which means that it is not considered a parsimonious model and should be discarded. According to the second-order models, the two specified factors had loads very close to one concerning their general factor. This is why it is not considered a stable model, since both specific dimensions can actually be part of a one factor model.

Our study considers the one-factor model more appropriate because it is more parsimonious and requires fewer assumptions. In addition, all factor loadings were greater than 0.71 (see Fig.  1 ). This decision was made because the other two models present overlap and the one-factor model is the most used and stable model found in other studies.

One-factor model of the GAD-7 score

Measurement invariance analysis between sex and age revealed that both groups were invariant, so comparisons could be made between each of these groups. Total scores can be compared between males and females or between age groups (adults vs. adolescents) as the ΔCFI and ΔRMSEA values remain at appropriate levels (see Table  3 ). In addition, the CFI and RMSEA values remained adequate for the configural, metric, and strong models. The configural level suggested that the different groups (men vs. women, and adults vs. adolescents) presented an equivalent factor structure, i.e., a seven-item, one-dimensional model. The metric level indicated that the different groups had equivalent factor loadings, and the strong level suggested that there were equivalent thresholds between the groups.

The internal consistency of the one-factor model was satisfactory (ω = 0.90; α = 0.93). The item-test correlation analysis indicated that, even if one item within the GAD-7 were eliminated, the internal consistency coefficient alpha would remain adequate in all cases (see Table  1 ). Therefore, eliminating one item would not affect the reliability of the scale.

A moderate correlation was shown between depressive symptoms and anxiety symptoms ( r  = 0.77), as other studies have shown. Therefore, it can be inferred that the instrument has convergent validity.

Main findings and interpretation

Our study validates a brief tool for measuring anxious symptoms, which represents a valuable resource for the development of mental health research and a potential screening tool in the primary care setting in Peru. Our study concluded that the GAD-7 score is valid and reliable according to the one-factor model. Internal structure validity evidence for the GAD-7 suggests that its seven items can be summed to obtain a total score. In addition, our study revealed that comparisons can be made between groups according to factors such as sex and age. For example, a comparison of GAD-7 scores can be made between men and women. Similarly, evidence of convergent validity indicates that the GAD-7 score in the Peruvian context is strongly related to depressive symptoms, which has been found in different studies, suggesting that the instrument behaves consistently with other studies. Finally, the GAD-7 score for the one-factor model presented optimal reliability values.

Our study revealed that the GAD-7 score has one factor. This finding is consistent with results reported in previous studies [ 21 , 23 , 51 ]. Other studies have suggested two-factor or higher-order models, but these results are not necessarily contradictory because these highly related dimensions are part of the same overall construct, anxiety symptoms [ 27 ]. Therefore, although somatic and cognitive-emotional factors are theoretically valid, they do not seem to be distinguishable at the empirical level in the general population [ 27 ].

A one-factor model indicates that the GAD-7 can use a total score and establish cutoff points with sensitivity and specificity values [ 36 ]. In addition, a Peruvian study also found adequate levels of sensitivity and specificity for GAD-7 with a cut-off of 10 points or more [ 52 ]. However, for models with two or more factors, sensitivity and specificity analyses must be performed for each factor. We did not find any sensitivity or specificity studies for the two-factor models of the GAD-7 score. Therefore, the one-factor model is more commonly used and studied.

Our results showed invariance of the GAD-7 score across sex and age. Although few studies have explored the invariance of the GAD-7 score, similar findings were obtained by [ 26 ], who found invariance across sex, age and marital status, level of education, and employment situation in Spanish primary care patients. Likewise, another study reported invariance regarding sex, strata, and linguistic background in a sample of patients after traumatic brain injury [ 23 ]. A study that included a Peruvian sample also reported invariance of the GAD-7 score and other short versions across sexes; however, only university students were considered [ 51 ]. The interpretation of our results suggests that, for the different groups, participants perceive the existence of a single factor consisting of seven items (configural invariance), indicating that the items have equivalent factor loadings, and therefore the items contribute equally to the construct (metric invariance). In addition, the thresholds of these items show equivalent values across groups, allowing for comparisons between groups (strong invariance) [ 29 ].

At the level of convergent validity, the GAD-7 score showed a moderate correlation with the PHQ-9 score, which measures depressive symptoms. These findings are consistent with the results of several studies that have shown a direct relationship between moderate and strong strength [ 23 , 24 , 27 , 31 ]. At the level of reliability, other studies have also shown that the GAD-7 has adequate internal consistency values for one-factor models [ 24 , 31 , 53 ].

Public health implications

In Peru, there are no clinical practice guidelines for the assessment, diagnosis or treatment of anxiety disorders. Our study allows the GAD-7 to be used as a scale to detect depressive symptoms in the general population. Because of its brevity, we recommended their use in future Peruvian clinical practice guidelines on anxiety from the Ministry of Health or Social Health Insurance (EsSalud). Considering that there are currently a study evaluating the sensitivity and specificity of different cut-offs for GAD-7 in the Peruvian population [ 52 ].

Strengths and limitations

The main strength of our study is the large sample size. Our study has several limitations. First, our study was not probability-based, so it cannot be generalized to other populations. Second, our study does not propose a cutoff point for determining whether participants have anxiety symptoms. Third, it was not possible to assess invariance with other groups of interest, such as marital status, chronic illness or economic status.

Conclusions and recommendations

Data availability.

Access to data will only be by convincing request.To review the manuscript we have enabled a link to our dataset https://zenodo.org/records/10600793 .

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Acknowledgements

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Universidad César Vallejo, Escuela de Medicina, Trujillo, Peru

David Villarreal-Zegarra

Escuela Profesional de Medicina Humana, Universidad Privada San Juan Bautista, Filial Ica, Ica, Peru

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Universidad San Ignacio de Loyola, Lima, Peru

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Instituto Peruano de Orientación Psicológica, Lima, Peru

David Villarreal-Zegarra, Rubi Paredes-Angeles, Nikol Mayo-Puchoc & Anthony Copez-Lonzoy

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David Villarreal-Zegarra: Formal analysis, methodology, supervision, validation, writing– original version, and approval of the final version. Rubi Paredes-Angeles: conceptualization, formal analysis, methodology, validation, writing– original version. Nikol Mayo: conceptualization, methodology, validation, writing– original version, and approval of the final version. Enoc: Methodology, Validation, Writing– Original version, Approval of the final version. Jeff Huarcaya-Victoria: Conceptualization, approval of the final version. Anthony Copez-Lonzoy: Conceptualization, Methodology, Validation, Writing– Review & Editing, Supervision, Approval of the final version.

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Villarreal-Zegarra, D., Paredes-Angeles, R., Mayo-Puchoc, N. et al. Psychometric properties of the GAD-7 (General Anxiety Disorder-7): a cross-sectional study of the Peruvian general population. BMC Psychol 12 , 183 (2024). https://doi.org/10.1186/s40359-024-01688-8

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Integrating Mindfulness and Acceptance Into Traditional Cognitive Behavioral Therapy During the COVID-19 Pandemic: A Case Study of an Adult Man With Generalized Anxiety Disorder

Alisa r. garner.

1 Department of Psychology, University of Tennessee-Knoxville, Knoxville, TN, 37996, USA

Gregory L. Stuart

Generalized Anxiety Disorder (GAD) can be chronic and impairing, highlighting the need for effective treatments. Although Cognitive Behavior Therapy (CBT) is an effective treatment for GAD, a number of patients continue to report GAD symptoms treatment. Integrating evidenced-based treatment components into CBT treatments, such as mindfulness- and acceptance-based treatment components found in Acceptance and Commitment Therapy (ACT), may help improve the efficacy of treatment. Emerging interventions and research suggest that the cognitive restructuring aspect of CBT and acceptance stance of ACT (e.g., cognitive defusion) can be implemented into treatment concurrently from a stance of increasing a patient’s coping skills repertoire and psychological flexibility. This systemic case analysis examined the efficacy and clinical utility of integrating ACT into a manualized CBT treatment for GAD. Furthermore, this study examined treatment efficacy and therapeutic alliance as the treatment rapidly and unexpectedly transitioned from in-person to telehealth due to the COVID-19 pandemic. Pre- to post-treatment and time-series analyses showed significant decreases in anxiety symptoms, worry, depressive symptoms, and emotion dysregulation. Although there was an initial increase in depressive and anxiety symptoms, worry, and emotion dysregulation following the switch from in-person to telehealth services, these quickly subsided and resumed a downward trend. The therapeutic relationship did not deteriorate during the transition to telehealth. This case study provides evidence of feasibility and efficacy of an integrated CBT/ACT approach in treating GAD. It also suggests that despite some temporary increase in symptoms, therapeutic alliance and treatment efficacy were not impacted by the switch to telehealth.

1 Theoretical and Research Basis for Treatment

Generalized anxiety disorder (GAD) is characterized by excessive, difficult to control, and psychosocial impairing anxiety and worry regarding multiple aspects of one’s life ( American Psychiatric Association, 2013 ). This anxiety and worry can manifest in symptoms such as restlessness, difficulty concentrating, muscle tension, fatigue, irritability, and difficulty sleeping. These symptoms occur most of the time over the course of six or more months. GAD has high comorbidity with other psychological disorders including major depressive disorders ( American Psychiatric Association, 2013 ). Approximately 3–4% of adults in the United States experience GAD in the past year and 7.8% report experiencing GAD in their lifetime ( Ruscio et al., 2017 ). GAD tends to be chronic in nature, following a course of periods of full or partial remission and relapse of symptoms. Over the course of 8 years, 43% of men and 36% of women will experience another episode of GAD ( Yonkers et al., 2003 ). Of respondents who reported a lifetime history of GAD, 48% reported experiencing GAD in the past year ( Ruscio et al., 2017 ). The high-risk of GAD recurrence highlights the need for effective treatments.

There are numerous cognitive behavior therapy (CBT) protocols and manuals to treat GAD. The CBT model of GAD suggests that uncontrollable worry associated with GAD is the result of threatening and catastrophic thoughts about future events ( LeBlanc et al., 2021 ). This worry serves as means of avoiding threatening, unpleasant experiences ( Lee et al., 2010 ). For example, the worry of the future threatening event causes an individual to engage in excessive checking behaviors or distract themselves from negative internal experiences. The worry is then maintained via negative reinforcement as it provides immediate relief and prevents the individual from engaging in effective coping strategies. Since the feared event did not occur, the worry creates a sense of control and predictability. CBT approaches focuses on changing the threatening thoughts through cognitive restructuring by evaluating the evidence and developing alternatives, as well as strengthening the patient’s belief that they can cope with unpleasant events ( Craske & Barlow, 2006 ). CBT protocols focus on psychoeducation about anxiety and worry, relaxation, cognitive restructuring, behavioral experimentation, and imaginal exposure ( LeBlanc et al., 2021 ). Meta-analyses showed CBT to be an effective treatment of GAD ( Carpenter et al., 2018 ; Hoffman et al., 2012 ). However, not all who complete treatment report remission of symptoms. For example, 62% of GAD patients had clinically significant improvement post-treatment which reduced to 56% at one year follow-up ( Öst & Breitholtz, 2000 ). This has resulted in a call for enhancing the efficacy of existing CBT therapies for GAD with empirically supported treatment components ( Behar et al., 2009 ).

Integrating mindfulness and acceptance treatment elements to existing CBT manuals may enhance the effectiveness of the treatment. The worry associated with anxiety can be conceptualized as a form of experiential avoidance. Experiential avoidance is the attempt to control or alter internal experiences even when it causes psychological suffering ( Hayes et al., 2012 ). This avoidance can result in the paradoxical effect of an increase in the avoided internal experiences ( Luoma et al., 2007 ). Hayes et al. (2012) developed Acceptance and Commitment Therapy (ACT) and suggested that addressing experiential avoidance involves developing a stance of mindfulness and acceptance. That is, to be aware of and experience fully, without judgment or defense, present-moment experiences. Mindfulness and acceptance, rather than avoidance, of internal experiences allows for flexibility in response and increasing behaviors that are in accordance with the patient’s values ( Luoma et al., 2007 ). Techniques such as cognitive defusion are utilized to help patients view thoughts as something they experience without literal meaning and implications. Mindfulness- and acceptance-based therapies, such as ACT, are effective treatments of GAD. A randomized controlled trial study compared CBT and ACT and found that both resulted in a reduction in GAD symptoms ( Stefan et al., 2019 ). Treatment components of mindfulness/acceptance therapies such as mindfulness exercises and valued actions are common in CBT treatments for GAD ( LeBlanc et al., 2021 ).

A mindfulness and acceptance stance within ACT emphasizes changing the relationship and reaction to thoughts (e.g., cognitive defusion). Since thoughts are experiences without literal meaning, the focus of treatment is not on the content of the thought but acceptance of the experience of thoughts coming and going. A CBT approach emphasizes changing the anxiety-provoking thought (e.g., cognitive restructuring). It may seem conflicting to incorporate these two perspectives into therapy. For example, Roemer & Orsillo (2007) developed Acceptance-Based Behavior Therapy for GAD with the specific purpose of blending CBT with ACT, but they did not include cognitive restructuring in their treatment and instead focused on acceptance of internal experiences. However, incorporating both approaches is possible. Ciarrochi and Bailey (2008) proposed an integrated approach where ACT and CBT techniques are offered to patients as a means of increasing the reservoir of coping skills. Patients develop the skill to identify under which circumstances ACT versus CBT techniques may be more helpful. When combining these two approaches therapists should explain to patients that these techniques promote thinking about thoughts differently and encourage whichever strategy is the most beneficial and thus promote psychological flexibility ( Blackledge, 2018 ; Wenzel, 2018 ). Case studies provide support for the successful implementation of a blended ACT/CBT approach for other problems including depression, chronic pain, and emotional difficulties ( Lunde & Nordhus, 2009 ; Marino et al., 2015 ; Pavlacic & Young, 2020 ). One small study found that combining CBT with ACT resulted in improvements in GAD symptoms ( Carrier & Côté, 2010 ).

COVID-19 and the Rapid Switch to Telehealth Services

The onset of the COVID-19 pandemic and the subsequent lockdowns resulted in in-person psychotherapy services being quickly shifted to telehealth (i.e., phone or video sessions). Telehealth is an effective method of treating mental health problems, including GAD, and its effectiveness is often comparable to in-person psychotherapy ( Poletti et al., 2021 ). However, previous studies on its effectiveness involved treatment where telehealth was provided for the entire course of therapy rather than treatment that shifted modalities during the therapy. This leaves questions on the impact this rapid switch had on the therapeutic relationship and the efficacy of treatment. Preliminary findings showed that the transition did not negatively impact the therapeutic relationship from the therapist’s perspective ( Stefan et al., 2021 ).

The following case study details the implementation of a traditional CBT manualized treatment for GAD while incorporating mindfulness- and acceptance-based principles in the treatment of a white, American male with GAD. Treatment involved use of the Mastery of Your Anxiety and Worry manual ( Craske & Barlow, 2006 ), an empirically supported CBT treatment for GAD ( Zinbarg et al., 2006 ), while integrating mindfulness and acceptance components from Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists ( Luoma et al., 2007 ). Furthermore, this case study details the implementation of this treatment as it shifted from in-person to telehealth due to the COVID-19 pandemic.

2 Case Introduction

The client’s name and identifying details were altered for confidentiality; however, the client’s symptoms and course of treatment remain the same. “Fred” was a 28-year-old, White, cis-gender, straight man, and graduate student, who self-referred to a large, southeastern university psychological clinic for relationship and anxiety-related concerns. Fred and his girlfriend of over one year had ended their relationship approximately one month prior to intake. The therapist was a female clinical psychology doctoral student who was under the supervision of two licensed clinical psychologists during this case.

3 Presenting Complaints

At intake, Fred reported symptoms of anxiety including excessive and difficult to control worry, restlessness, difficulty concentrating, muscle tension, and difficulty sleeping. These symptoms persisted for over the past year. Fred described a long history of anxiety, beginning in childhood, and his most recent exacerbation in anxiety symptoms coincided with his relationship with his girlfriend at the time. He explained he would become highly anxious regarding multiple aspects of the relationship including how he and his girlfriend would spend their time together and he was excessively concerned with his girlfriend’s wellbeing. Fred would attempt to alleviate and control the anxiety and worry. For example, before spending time with his girlfriend he would thoroughly plan out their activities. He would often leave his home in the middle of the night to console his girlfriend when she was upset. He described being preoccupied by and frequent rumination on his anxious thoughts to the point that he was unable to think about anything else or engage in other activities. Fred would often come to catastrophizing conclusions about himself while ruminating on his anxious thoughts and experience fear and panic that these evaluations about himself were true. Fred also noted when his anxiety was particularly high this would result in avoidance. He would worry that he was not a “good” boyfriend resulting in urges to end the relationship and eventually became overwhelmed to the point he ended the relationship. While Fred was primarily concerned with the anxiety and worry related to his relationship, he also described a history of anxiety and worry, along with attempts to control or avoid the anxiety, in other contexts including school performance and familial relationships.

Fred described several depressive symptoms including a saddened mood, loss of interest in pleasurable activities, and loss of appetite, as well as difficulty concentrating and sleeping. He reported the onset of these symptoms began when he ended the relationship with his girlfriend one month prior. Fred did not report any difficulties with substance use and did not report any suicidal ideation or intent. There were no concerns regarding personality disorders or traits.

Fred was raised by biological, married parents who eventually divorced when Fred was in his mid-20’s. Fred is the youngest child with one older brother. He reported meeting all developmental milestones on time and no significant physical health problems. He noted a family history of mental health difficulties including anxiety and depression. He described a consistently positive relationship with his family; however, he noted feeling as if he was his mother’s caretaker, even as a child, when it came to her mental and physical health struggles.

Fred’s anxiety symptoms began in childhood. He described anxiety whenever he was separated from his family, worry about his performance in school, and difficulty sleeping due to rumination. As a teenager, Fred would experience anxiety regarding romantic relationships, specifically worry that he would not be/was not a good enough partner, which prevented him from obtaining and developing long-term, intimate relationships. As an adult Fred’s anxiety was primarily related to relationships, his performance in school compared to his peers, and his mother’s health. He engaged in psychotherapy twice prior to intake due to his anxiety and difficulty obtaining and maintaining intimate relationships. Fred was prescribed Valium (benzodiazepine) in his early 20’s. He stated they were prescribed “as needed” to help him sleep.

Fred began his graduate studies in his mid-20’s. During his second year, he began his relationship with his first serious, long-term girlfriend who attended the same graduate program. Fred noted his anxiety regarding the relationship increased as the relationship continued. He stated that towards the end he and his partner were having verbal arguments at least once a week. Fred described the relationship as unstable and “too hard.” He noted his ability to handle his anxiety related to other stressors began to diminish. He felt overwhelmed by these worries and ended his relationship of over one year with his girlfriend despite still having intimate feelings.

5 Assessment

Fred’s psychosocial history was gathered over the course of two intake sessions. Fred completed a clinical interview and the Diagnostic Interview of Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND, Tolin et al., 2018 ) along with the following measures: the Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002 ), the Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006 ), the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004 ); the Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011 ), and the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995 ). The Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990 ) and the Working Alliance Inventory-Short Form Revised (WAI-SR; Hatcher & Gillaspy, 2006 ) were administered one month after the beginning of treatment. These seven measures were also administered throughout treatment, termination, and one month post treatment at varying frequencies to reduce patient burden. The PHQ-9 and GAD-7 were administered prior to every therapy session, as well as at termination and one month post treatment. The DERS, PSWQ, and WAI-SR were administered monthly, as well as at termination and one month post treatment. The AAQ-II was administered at termination and one month post treatment, while the DASS-21 was administered at termination.

The DIAMOND ( Tolin et al., 2018 ) is a semi-structured clinical interview that assesses for symptoms that meet diagnostic criteria for several Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013 ) disorders. Patients are queried on different DSM-5 symptoms and any associated distress or impairment due to the endorsed symptoms. A diagnosis may be warranted when the patient endorses all the listed symptoms and criteria for a given disorder. The DIAMOND is a reliable and valid semi-structured diagnostic interview for DSM-5 disorders ( Tolin et al., 2018 ).

The PHQ-9 ( Kroenke & Spitzer, 2002 ) is a nine-item, self-report measure of depressive symptoms. The nine depressive symptom items are rated on a 4-point Likert scale ranging from 0 ( Not at all ) to 3 ( Nearly every day ). Total scores range from 0 to 27, with higher scores indicating greater depression severity. Cutoff points of 5, 10, 15, and 20 indicate mild, moderate, moderately severe, and severe depression, respectively. The PHQ-9 is a reliable and valid measure of depressive symptoms ( Beard et al., 2016 ).

The GAD-7 ( Spitzer et al., 2006 ) is a seven-item, self-report measure of GAD symptoms. Scored items on GAD-7 are rated on a 4-point Likert scale ranging from 0 ( Not at all ) to 3 ( Nearly every day ) with total scores ranging from 0 to 21. High scores on the GAD-7 suggest more severe GAD symptoms. The GAD-7 includes cutoff points of 5 (mild anxiety), 10 (moderate anxiety), and 15 (severe anxiety). This measure demonstrated good psychometric properties among clinical populations ( Spitzer et al., 2006 ).

The DERS ( Gratz & Roemer, 2004 ) is a 36-item, self-report measure of emotional dysregulation. Respondents rate items on the DERS on a 5-point Likert Scale ranging from 1 ( almost never [0–10%] ) to 5 ( almost always [91–100%] ). Responses are summed to obtain a total score ranging from 36 to 180 with higher scores suggesting greater emotional dysregulation. The DERS is a reliable and valid assessment of emotional dysregulation ( Hallion et al., 2018 ).

The AAQ-II ( Bond et al., 2011 ) is a seven-item, self-report measure of lack of acceptance, avoidance, and psychological inflexibility related to emotions, memories, and experiences that may make living life according to one’s values difficult. Items on the AAQ-II are rated on a 7-point Likert scale ranging from 0 ( never true ) to 7 ( always true ). Total scores range from 0 to 49, with higher scores indicating greater psychological inflexibility. The AAQ-II demonstrated good psychometric proprieties among a variety of populations ( Bond et al., 2011 ).

The DASS-21 ( Lovibond & Lovibond, 1995 ) is a 21-item, self-report measure comprising of three subscales measuring the symptom severity of depression, anxiety, and stress. Items are rated on a 4-point Likert scale ranging from 0 ( did not apply to me at all ) to 3 ( applied to me very much or most of the time ). The respective items for each subscale are summed and then multiplied by two to obtain each subscale’s total score, ranging from 0 to 42. High scores on the subscales reflect greater symptom severity. The cutoffs for the Anxiety subscale are 8 (mild), 10 (moderate), 15 (severe), and 20+ (extremely severe). The cutoffs for the Depression subscale are 10 (mild), 14 (moderate), 21 (severe), and 28+ (extremely severe). Last, the cutoffs for the Stress subscale are 15 (mild), 19 (moderate), 26 (severe), and 34+ (extremely severe). The DASS-21 is a reliable and valid measure within clinical samples ( Antony et al., 1998 ).

The WAI-SR ( Hatcher & Gillaspy, 2006 ) is a 12-item, self-report measure of therapeutic alliance. Respondents rate items on a 5-point Likert scale ranging from 1 ( never ) to 5 ( always ). A mean total score is achieved by summing items and dividing the sum by 12 with scores ranging from 1 to 5. Higher scores indicate greater therapeutic alliance. The WAI-SR demonstrated good psychometric properties among clinical populations ( Munder et al., 2010 ).

The PSWQ ( Meyer et al., 1990 ) is a 16-item, self-report measure of worry that is typically present with GAD. Items are rated on a 5-point Likert Scale ranging from 1 ( not ta all typical of me ) to 5 ( very typical of me ). Items are summed to obtain the total score, ranging from 16 to 80, with higher scores indicating greater worry. The PSWQ displayed good psychometric properties among clinical samples ( Fresco et al., 2003 ).

6 Case Conceptualization

Fred’s clinical presentation was consistent with a DSM-5 ( American Psychiatric Association, 2013 ) diagnosis of GAD. While he reported several depressive symptoms, given the overlap in his depressive symptoms with his GAD symptoms (e.g., difficulty sleeping, difficulty concentrating), assessment data, and the situational nature, a mood disorder diagnosis was not provided at intake nor during treatment. Fred’s case conceptualization is based on the Mastery of Your Anxiety and Worry: Therapist Guide ( Zinbarg et al., 2006 ) which is derived from the theoretical models by Barlow (2002) and Zinbarg (1998) . Fred’s developmental learning history reinforced a belief that he was “not good enough,” “incompetent,” and “bad.” As a child, Fred felt responsible for the needs of his emotionally and physically ill mother but felt his attempts were unsuccessful as her illnesses continued. In his teenage years, Fred’s attempts to obtain and maintain intimate relationships were equally unsuccessful despite putting forth a great deal of effort. This sense of failure despite his efforts created a sense of uncontrollability and unpredictability in his life. This resulted in a cognitive bias to scan for threats, interpreting ambiguous events as threatening, and automatic thoughts that were catastrophizing and “all or nothing” which resulted in anxiety and worry. To control this anxiety and worry, Fred engaged in preventative behaviors (e.g., thoroughly planning his time with his girlfriend to ensure she was happy) or avoidance behaviors (e.g., immediately going to his girlfriend whenever she was upset). These behaviors would provide Fred with immediate relief and a sense of controllability over his feelings, thus maintaining the cycle of anxiety/worry and avoidance. Fred viewed any amount of anxiety and worry as “pathological” and would experience distress at its presence. This resulted in a cycle of worry about worrying as an attempt to control the worry and anxiety.

Treatment Plan

Fred’s reported goals for treatment included reducing his symptoms of anxiety, especially anxiety related to intimate relationships and gaining the ability to have an intimate relationship. He also wanted to understand the nature of his catastrophizing thoughts about himself without fear of what these thoughts mean about himself. In order to address his treatment goals, intervention began utilizing the Mastery of Your Anxiety and Worry manual ( Craske & Barlow, 2006 ) and incorporated mindfulness- and acceptance-based interventions from Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists ( Luoma et al., 2007 ) when needed and upon completion of the manual.

7 Course of Treatment and Assessment of Progress

Treatment consisted of 29 weekly and every-other-week sessions over 10 months. Treatment began in-person with 11 sessions. Four months into treatment the COVID-19 pandemic resulted in therapy sessions being moved to phone sessions for 15 sessions and then videoconferencing sessions for 3 sessions to termination. Fred remained on his prescription of Valium throughout treatment, using “as needed,” once or twice a month, as a sleep aid.

In-Person Sessions: Pre–COVID-19

Sessions 1–4: introduction to treatment and psychoeducation.

Treatment began with clarifying Fred’s treatment goals, developing a treatment plan, and introducing him to the manual. Fred learned about the nature and function of anxiety, as well as developed insight into his learning history that contributed to his anxious beliefs about himself and the world. Fred acknowledged struggling with the concept of automatic thoughts but agreed to engage in the self-monitoring assignments including the “Worry Record” to help him recognize and identify his automatic thoughts, as well as develop insight into his avoidance behaviors. Throughout the remainder of treatment, Fred diligently completed his homework assignments and self-monitoring assessments. During this time, Fred’s ex-girlfriend had asked if they could remain friends, which Fred declined. Fred came to the realization that this decision was an example of his avoidance behaviors. He decided to remain friends with his ex-girlfriend to better address his anxiety and improve his relationship with his ex-girlfriend, especially since he would have to regularly see his ex-girlfriend as they attended the same graduate program.

Sessions 5–8: Relaxation and Cognitive Restructuring

Fred was introduced to progressive muscle relaxation training. It was explained to him that the goal of progressive muscle relaxation training was to help Fred develop the ability to physically relax by focusing attention on the physical sensation of tensing and relaxing various body parts. The importance of following the practice outlined in the manual was stressed and that the benefits would include eventually developing the ability to relax his entire body in one step. Through use of the “Worry Record,” Fred noticed a tendency to over-estimate his anxiety. He began noticing situations which would previously evoke a high anxiety rating were now eliciting lower levels of anxiety. Fred began developing the skills to identify his automatic anxious thoughts. Initially, Fred struggled to understand why the automatic thoughts he identified in his Worry Records would provoke anxiety. For example, thoughts that if he did not study he would fail the test did not feel particularly distressing. Fred was encouraged to ask, “if this thought is true, what would it mean about me?” to get at the underlying meaning and worry. Fred noticed themes of perfectionism, that he is not “good enough,” “unworthy” of others, “incompetent,” and “bad,” and responsible for the wellbeing of his loved ones, in his anxious thoughts. Fred learned to identify the assumed risk associated with, and the tendency to catastrophize within, his anxious thoughts. Fred began considering the probability of these risks and worst-case-scenarios coming true and developing alternative possibilities. While he noticed reduction in his anxiety after engaging in these cognitive restructuring skills, he would occasionally report distress that his anxiety was not “going away.” The therapist would highlight how the same themes of perfectionism and tendency to catastrophize were resulting in anxious thoughts about his anxiety and encouraged Fred to utilize his cognitive restructuring skills when experiencing these thoughts.

Sessions 9–11: Imagined Exposure

Fred continued to practice the progressive muscle relaxation training. He reported improvement in his relaxation ratings warranting moving to the one-step, cued recall relaxation. He initially found that he did not achieve as much relaxation with the one-step practice and would occasionally revert to the four-muscle group practice. Fred was introduced to imagery exposure, or the practice of imagining the worst-case scenarios without avoidance to reduce the anxious response these images can cause. Fred picked an image to practice in session that corresponded to an anxious thought from the prior week. Fred described the scenario in session and rated his anxiety and the vividness of the image on a 0 ( None ) to 100 ( Extreme ) scale. By the end of the exercise, Fred reported high levels of vividness, a 50 or higher on the 1 to 100 scale, but only achieved the highest rating of 30 on the anxiety scale. Fred was encouraged to continue practicing the imagery exposure and to utilize memories and take the memory to the extreme scenario to help elicit an anxious response. Fred continued to practice at home, but despite high levels of vividness of the images (highest of 75 on a 1 to 100 scale) his anxiety levels peaked at 40, on a 1 to 100 scale, and in subsequent practices his anxiety did not get higher than 40. Fred and the therapist brainstormed these issues, checking that Fred was not engaging in avoidance and that his images were specific and vivid. The therapist noted how through the process of identifying the probability of these scenarios and developing alternative plans, these images may not be evoking heightened anxiety because Fred has already recognized that they were not likely to occur or were manageable. This is consistent with the inhibitory learning approach of exposure therapy which suggests that the anxiety/fear response is due to the consistent pairing of a neutral stimulus with an adverse stimulus ( Craske et al., 2014 ). Thus, an important aspect of exposure therapy from this perspective is for the patient to notice the discrepancy between their expectation and the outcome. Craske et al. (2014) note that cognitive interventions such as cognitive restructuring being utilized prior to or during exposure could lessen the effectiveness of exposure due to reducing the severity of the patient’s expectations and creating a decreased mismatch between expectancy and outcome. As a result, Craske et al. (2014) recommended such cognitive interventions occurring after the exposure portion of therapy. After several weeks of practice, without producing high levels of anxiety, Fred and the therapist agreed Fred could discontinue the practice to devote more time to coping skills Fred found more useful.

Fred continued to examine his anxiety utilizing the “Worry Record.” When he had difficulty getting to the personal meaning of his anxious thoughts, Fred would make a point to bring these “Worry Records” into the session to brainstorm with the therapist the personal meaning. Fred continued to engage in his friendship with his ex-partner. He noticed urges to engage in previous safety behaviors such as go to her home when she was upset but would not act on these urges. Fred began to discuss with the therapist uncertainty and confusion that his hesitancy in rekindling his relationship with his ex-girlfriend was due to avoidance and anxiety, or a lack of intimate feelings for her. The therapist lead Fred in a values clarification exercise where Fred described what actions he would be engaging in if he were living a life in line with his values. The therapist noted that at times following his values would be anxiety provoking, as often our values reveal our vulnerabilities ( Wilson & Sandoz, 2008 ). The therapist had Fred reflect on the difference between anxiety from engaging in valued action versus anxiety from a place of worry and avoidance. Fred was encouraged to consider his values and if a relationship with his ex-partner felt like it was moving towards or away from those values to clarify if his hesitancy was coming from avoidance, anxiety from trying something new but values consistent, or a lack of intimate feelings for his ex-partner.

Phone Sessions: COVID-19

At this point in treatment, the COVID-19 pandemic hit the local area of the university psychological clinic resulting in its closure. With the uncertainty of the situation, the clinic created the policy that clients would receive the following based on level of client’s need: temporary pause in treatment, 15-minute phone check-ins, or phone sessions. Given that Fred was two or three sessions away from completing the manual, the therapist was allowed to complete the final sessions via phone sessions. Fred agreed to this plan.

Sessions 12–14: Behavioral Changes and Completion of the Manual

Fred initially reported increased and “constant” anxiety symptoms due difficulties regarding his ex-girlfriend, finals, family medical issues, and changes related to the COVID-19 pandemic including the suddenness of the upcoming ending of treatment. He noted that he continued to practice the cued recall relaxation but due to the increased anxiety was finding it difficult to notice the reduction in physical tension. Fred’s anxiety symptoms subsided as he continued to practice his cognitive restructuring skills.

Fred had begun to examine the behaviors he engaged in when worried and anxious, particularly his tendency to immediately leave anxiety provoking situations or engage in safety checking behaviors. He developed and began engaging in alternative behavioral practices such as staying in the anxiety provoking event until he engaged in one of his coping skills (e.g., cognitive restructuring, cued recall relaxation). Fred and the therapist discussed information from the manual on goal setting and problem solving to develop a plan of implementing his coping skills in anxiety provoking situations. Fred developed a plan to continue to practice his copings skills after therapy was terminated, including utilizing the “Worry Records” and the cued recall relaxation. The therapist highlighted the improvements Fred had made over the course of treatment and encouraged him to enact his plan after treatment.

Sessions 15–21: Reinforcing Skills and Incorporating Mindfulness and Acceptance

At this point in treatment, the university’s psychological clinic’s policy shifted so that telehealth sessions would be the norm. Fred agreed to continue treatment and his treatment continued without interruption. With the completion of the manual, the therapist and Fred agreed treatment would focus on Fred’s continued practice of his cognitive restructuring and relaxation skills, while also developing and incorporating mindfulness and acceptance into his coping skillset.

While Fred and his ex-girlfriend had explored the possibility of resuming their intimate relationship, after consideration of his values Fred concluded that he did not want to resume an intimate relationship. Fred reported he was sad about this decision, but he was comfortable in continuing being friends with her. Fred continued to examine his anxious thoughts and utilized his cognitive restructuring skills. Fred and the therapist began discussing mindfulness and acceptance. Fred was introduced to mindfulness as the practice of present moment awareness with curiosity and acceptance. He learned that acceptance is the opposite of avoidance and is an attitude of allowing all experiences to occur without trying to control or change the experiences. Fred explored how being caught up in his anxious thoughts prevented him from experiencing life and kept him in the same pattern of anxiety and avoidance. He recognized his avoidance behaviors were often inconsistent with his values. The therapist acknowledged the difference in taking an acceptance stance compared to cognitive restructuring. The therapist encouraged Fred to consider which approach felt most beneficial in the moment, try it, and then move onto another if the first coping skill was not effective. It this way, Fred would develop flexibility in his approach to his anxiety rather than remain in the same ridge pattern.

Fred began practicing mindfulness and acceptance of his anxious thoughts and emotions. As he noticed anxious thoughts, he would acknowledge the thought and remind himself that it is “just a thought” and something separate from himself. Fred noted finding it easier to allow and accept the anxiety related to things such as school and his future; however, he continued to experience his anxiety with “relationships” as “bad.” In session, Fred explored the negative associations linked with “relationships” including that he will always fail in relationships and that relationships were filled with uncertainty. Fred realized how the fusion of these rules and judgments to “relationships” was resulting in avoidance of developing and fostering intimate relationships. He began practicing the ACT defusion technique of repeating the word “relationship” for a minute to disentangle the meaning he had placed on the word “relationship” and open space to act according to his values rather than avoidance. Fred also began to practice using the phrase “I’m having the thought…” when he noticed experiencing words or thoughts that evoked painful emotions to separate himself from his thoughts.

Sessions 22–26: Values and Flexibility in Utilizing Coping skills

Fred and the therapist returned to a discussion about Fred’s values. Fred developed an understanding that there are times in his life where living according to his values came with anxiety, but he accepted this anxiety because it meant moving in accordance to his values. Fred reflected on the different thoughts and feelings that were evoked when he experienced anxiety while moving towards his values versus when he was trying to move away from the anxiety with avoidance. Fred was introduced to and encouraged to practice “willingness” or making the choice to sit with the thoughts and emotions that comes with choosing acceptance and working towards his values. Fred began to develop committed actions that were in line with his values and he and the therapist would reflect on his committed actions in session. Fred continued to utilize the coping skills developed throughout treatment including cognitive restructuring, cued relaxation recall, mindfulness, and acceptance, in a flexible manner. He considered which coping skill would be most beneficial given the circumstances and which would help him move towards his values. Fred reported improvements in managing his anxiety and a decrease in his view of remaining anxiety as “bad” or pathological. Fred and the therapist agreed to move towards termination.

Videoconferencing Sessions: COVID-19

Sessions 27–29: wrap up and termination.

Fred and the therapist agreed to conduct sessions via videoconferencing in line with the change in the clinic’s policy. Fred discussed his plans and the coping skills he could utilize to handle anxiety as he pursues a new relationship, completes graduate school, and completes therapy. Fred told his ex-girlfriend that he was ready to begin dating other women. He noted the conversation was sad and difficult, but he was able to sit with those feelings and realize they were the result of mourning the end of his relationship rather than an indication there was something wrong with him. Fred signed up on dating applications and though he experienced nervousness and anxiety as he began taking steps towards dating again, he reported willingness to engage in these committed actions and move towards his values. Fred went on a date and noted that he was able to accept the anxiety he experienced while on the date. Fred also experienced sadness and anxiety regarding nearing completion of his graduate program but he again reported being able to accept and not be overwhelmed by the anxiety and willingly engage in the next steps of looking for a job. He noted feeling “bittersweet” that therapy was coming to an end, feeling both nervous but ready to practice his skills on his own. Fred reported the biggest changes he saw in himself was his understanding of his anxious thoughts and his increased acceptance. Fred expressed his appreciation for the therapist’s flexibility in treatment modalities that fit his needs.

Assessment of Progress

Baseline assessment.

At intake, Fred reported mild (PHQ-9 = 9) and moderate (DASS-21 Depression = 16) depression symptoms, and moderate (GAD-7 = 11; DASS-21 Anxiety = 12) anxiety symptoms. He scored in the normal range for stress (DASS-21 Stress = 12). Fred scored below average among clinical samples on the DERS (88; M = 89.33, Hallion et al., 2018 ) and AAQ-II (24; M = 28.34, Bond et al., 2011 ), suggesting slightly better than average emotion regulation and psychological flexibility compared to clinical samples. At one month into treatment, Fred scored below average compared to clinical samples on the PSWQ (60; M = 68.11, Fresco et al., 2003 ) and WAI-SR (3.42; M = 3.8, Munder et al., 2010 ), suggesting slightly lower than average symptoms of worry and therapeutic alliance compared to clinical samples.

Post-Treatment Assessment

For measures only administered at baseline and termination, Reliable Change Index (RCI) scores were calculated to assess clinically significant and reliable change. Statistical significance in changes were determined by comparing his baseline and termination scores to means reported by general and clinical populations ( Jacobson & Truax, 1991 ). The difference in baseline and termination scores was divided by the standard error of measurement to obtain the RCI. An RCI score that exceeds the z score for the 97 th percentile (−1.96 or 1.96) indicates a change that is statistically significant ( p < .05). Fred’s termination assessment showed significant improvements in depression, anxiety, and stress (see Figure 1 ). His scores on the DASS-21 Depression (0) and Anxiety (0) subscales dropped to the normal range, while his score on the DASS-21 Stress (2) remained in the normal range. These changes showed statistically significant reductions in depression (RCI = 3.78, p < .05), anxiety (RCI = 5.20, p < .05), and stress (RCI = 3.94, p < .05) symptoms. While Fred’s AAQ-II score reduced to 18 at termination, this change was not statistically significant (RCI = 6.43).

Baseline and Termination changes on the AAQ-II and DASS-21 Subscales. Note. AAQ-II = Acceptance and Action Questionnaire-II. DASS-21 = Depression Anxiety Stress Scales-21. Reduction in DASS-21 scores significantly decreased over time. AAQ-II score at termination was not significantly lower than intake score.

For measures administered regularly throughout treatment, Simulation Modeling Analysis (SMA; Borckardt et al., 2008 ) was utilized to examine linear change in assessments through the course of treatment. SMA is a time-series analysis technique for short time-series data which accounts for autocorrelations among values. Slope vectors were examined to assess the linear change in assessments. Linear regression using SPSS 27.0 were then examined to confirm the SMA results. See Figure 2 for weekly assessments (PHQ-9, GAD-7) and Figure 3 for monthly assessments (DERS, PSWQ). For Fred’s PHQ-9 assessments, results of the regression analyses showed time in treatment explained 55% of the variance, R 2 = .551, F (1, 28) = 34.34, p < .001, and significantly associated with a decrease in PHQ-9 scores ( β = −.742, p <.001). Fred’s PHQ-9 score was 0 at termination, indicating “None/Minimal” depressive symptoms. Analysis of Fred’s GAD-7 scores showed time in treatment explained 63% of the variance, R 2 = .628, F (1, 28) = 47.27, p < .001, and significantly associated with a decrease in GAD-7 scores ( β = −.792, p <.001). Fred’s GAD-7 score of 2 at termination suggested “None to Minimum” anxiety symptoms. Fred’s PSWQ analysis results showed time in treatment explained 75% of the variance, R 2 = .752, F (1, 10) = 30.25, p < .001, and significantly associated with a decrease in PSWQ scores ( β = −.867, p <.001) with a score of 38 at termination. Time in treatment explained 77% of the variance, R 2 = .769, F (1, 10) = 33.28, p < .001, and significantly associated with a decrease in DERS scores ( β = −.877, p <.001) with a score of 51 at termination. Last, results of the regression analysis for the WAI-SR showed time in therapy did not significantly associate with change in WAI-SR scores ( β = −.457, p =.135). While Fred initially showed a slightly lower than average therapeutic alliance compared to clinical samples at the beginning of treatment, the remainder of his scores were above average.

Changes in Anxiety and Depression Symptoms. Note. GAD-7 = Generalized Anxiety Disorder-7; PHQ-9 = Patient Health Questionnaire-9

Changes in Worry and Emotion Dysregulation. Note. DERS = Difficulties in Emotion Regulation Scale; PSWQ = Penn State Worry Questionnaire.

Additionally, examination of these assessments showed increased scores on the PHQ-9, GAD-7, PSWQ, and DERS during the time of transition from in-person therapy to phone sessions as a result of COVID-19. However, Fred’s scores quickly returned to similar or lower levels than they were before the switch and resumed their downward trend. Fred’s WAI-SR were not impacted during the switch to telehealth services.

8 Complicating Factors

While Fred actively engaged in treatment, there were occasions when the therapist and Fred would decide to spend additional sessions on a chapter of the manual rather than move forward. Fred reported struggling with identifying his automatic anxious thoughts, especially ones that were meaningful. As a result, the therapist and Fred agreed to spend additional sessions focusing on identifying meaningful automatic anxious thoughts. When engaging in imagined exposure, Fred would experience highly vivid images, but the images would not provoke equally anxious responses. Fred engaged in the practice for several weeks and he and the therapist spent several sessions brainstorming the reason for the difficulty. However, he was never able to produce a heightened anxious response. The therapist and Fred agreed that Fred could discontinue the practice since it did not appear to be an effective exercise for Fred.

The largest complicating factor of this case is the disruption in treatment due to the COVID-19 pandemic. There were several weeks of uncertainty in the situation which caused a rush in completing the manual via phone sessions. During the termination session, Fred noted the difficulties in the shift from in-person to phone sessions including not being able to see body language and not having a physical location that was solely dedicated to therapy. He added that therapy felt like it improved after switching to videoconferencing session.

9 Access and Barriers to Care

Fred’s graduate program provided financial support for their students to receive care through the university psychological clinic, thus eliminating financial costs as a barrier for care. As Fred and the therapist were both students, their schedules only overlapped by one day. Thus, if either could not meet on their scheduled day, then they were unable to reschedule for a different day that week. Furthermore, Fred would often use breaks in the university schedule to return home to visit his family. This resulted in several cancelations over the course of treatment.

10 Follow-Up

A follow-up session was conducted one month after termination. Fred reported managing his anxiety utilizing his coping skills and has continued to willingly engage in committed actions despite anxieties related to dating and his future career. He added that he has accepted that anxiety is a part of his life rather than something he wished was gone from his life. Fred reviewed his plans to continue managing his anxiety and engage in committed action.

Analyses of follow-up assessments showed Fred’s AAQ-II score slightly increased with a score of 18 at termination to 19 at one-month follow-up. The change in his AAQ-II score from baseline assessment was not significant (RCI = 6.43). SMA and corresponding linear regression analyses were examined to see linear progression of assessments from beginning of treatment to one-month follow-up (See Figures 2 and ​ and3). 3 ). Time in treatment significantly associated with a decrease in PHQ-9 scores ( β = −.717, p <.001) and GAD-7 scores ( β = −.764, p <.001). Fred’s anxiety (GAD-7 = 2) and depression (PHQ-9 = 0) remained at “None to Minimal” levels at one-month follow-up. Time in treatment also significantly associated with a decrease in PSWQ scores ( β = −.832, p <.001) and DERS scores ( β = −.825, p <.001), but was not significantly associated with change in WAI-SR scores ( β = .044, p =.902). Fred’s worry and emotion dysregulation rose slightly from termination (PSWQ = 38; DERS = 51) at one-month follow-up (PSWQ = 46; DERS = 56), while his WAI-SR score remained the same (4.67).

11 Treatment Implications of the Case

Both CBT and mindfulness- and acceptance-based therapies demonstrated efficacy in the treatment of GAD ( Carpenter et al., 2018 ; Hoffman et al., 2012 ; Stefan et al., 2019 ). Blending the two approaches may be beneficial in that it increases the patient’s coping skills repertoire and psychological flexibility ( Blackledge, 2018 ; Ciarrochi & Bailey, 2008 ; Wenzel, 2018 ). The current case study provides evidence of the feasibility and efficacy of a blended CBT/ACT approach for GAD. Fred’s depressive and anxiety symptoms, emotion dysregulation, and worry significantly decreased throughout treatment and at follow-up. His AAQ-II score reduction did not significantly change and increased slightly at follow-up, suggesting Fred may have benefited from additional time devoted to ACT interventions. Only one prior study demonstrated the feasibility and benefit of incorporating ACT into CBT for GAD ( Carrier & Côté, 2010 ). However, this study only had three participants. Future research should examine the efficacy of an integrated approach in larger, diverse samples. Additionally, this case study examined the efficacy of treatment and the therapeutic alliance during the switch from in-person to telehealth. Fred did show a slight increase in depressive and anxiety symptoms, emotion dysregulation, and worry during the transition from in-person to telehealth, but this temporary increase quickly subsided. The therapeutic alliance was not impacted during the transition. This suggests that the shift from in-person to telehealth did not negatively impact the efficacy of treatment or the therapeutic relationship. It should be noted that the therapeutic alliance was high prior to the shift. It is possible that the strength of the therapeutic alliance and frequent communication with Fred regarding the changes in clinic policy helped ameliorate potential problems.

12 Recommendations to Clinicians and Students

The current case study suggests students and clinicians should consider using a flexible approach in treating GAD. Students and clinicians should consider the techniques in CBT and ACT that would benefit the patient given their case conceptualization and treatment plan. Both cognitive restructuring and cognitive defusion skills can be incorporated within the same treatment when they are framed as different ways of approaching thoughts that may be beneficial in certain situations versus others. Clinicians and students should take the time to address any confusion by their clients when incorporating both approaches and help their patients develop an understanding of when one technique may be more beneficial than the other. Furthermore, flexibility in how the treatment is implemented whether it is in-person or telehealth should be considered given the patient’s case conceptualization, treatment plan, and other external factors.

Author Biographies

Alisa R. Garner , M.A. is a clinical psychology doctoral student at the University of Tennessee. She received her B.S. from Weber State University and M.A. from Midwestern State University. Her research interests include risk factors for engagement in sexual risk-taking and perpetration of sexual aggression and coercion.

Gregory L. Stuart , Ph.D. is a Professor of Psychology and Director of Clinical Psychology Training at the University of Tennessee-Knoxville. His research focuses primarily on the comorbidity of intimate partner violence and substance use. He is particularly interested in interventions that address both substance use and relationship aggression.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by grant F31AA028150 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) awarded to the first author. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAAA or the National Institutes of Health.

Ethical Approval: All identifying information that was not deemed central to the conceptualization and treatment of this client has been removed to maintain confidentiality. Additionally, the patient signed a consent form for their case to be used for publication.

Alisa R. Garner https://orcid.org/0000-0002-0267-4485

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The Impact of Cognitive Behavioral Therapy on Sleep Problems in Autistic Children with Co-occurring Anxiety

• Brief Report
• Published: 01 April 2024

Cite this article

• Holly K. Harris   ORCID: orcid.org/0000-0001-5512-755X 1 , 8 ,
• Minjee Kook 2 ,
• Peter Boedeker 2 , 3 ,
• Andrew G. Gusick 4 ,
• Ariel M. Lyons-Warren 1 , 5 ,
• Robin P. Goin-Kochel 1 , 6 ,
• Chaya Murali 7 ,
• Leandra N. Berry 1 , 6 &
• Eric A. Storch 2  

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This study seeks to examine the relationship between anxiety-symptom severity and sleep behaviors in autistic children receiving cognitive behavioral therapy (CBT).

We conducted a secondary-data analysis from a sample of 93 autistic youth, 4 to 14 years, participating in 24 weeks of CBT. Clinicians completed the Pediatric Anxiety Rating Scale (PARS) and parents completed the Children’s Sleep Habits Questionnaire, Abbreviated/Short Form (CSHQ-SF) at baseline, mid-treatment, post-treatment and 3 months post-treatment. Mediation analysis evaluated the role of anxiety symptoms in mediating the effect of time in treatment on sleep.

There was a negative association between time in treatment and scores on the CSHQ-SF (b = − 3.23, SE = 0.493, t = − 6.553, p  < 0.001). Increased time in treatment was associated with decreased anxiety (b = − 4.66, SE = 0.405, t = − 11.507, p  < 0.001), and anxiety symptoms decreased with CSHQ-SF scores (b = 0.322, SE = 0.112, t  = 2.869, p  = 0.005). The indirect effect of time in treatment on CSHQ-SF scores through PARS reduction was negative, but not statistically significant.

Increased time in CBT was associated with decreased anxiety severity and improved sleep behaviors. Reductions in anxiety symptoms may mediate improvements in sleep problems, but larger sample sizes are necessary to explore this further.

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Acknowledgments

This study was partially supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number P50HD103555. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.  We are grateful to all of the families in SPARK, the SPARK clinical sites and SPARK staff.  We appreciate obtaining access to phenotypic data on SFARI Base. Approved researchers can obtain the SPARK population dataset described in this study by applying at https://base.sfari.org . We appreciate obtaining access to recruit participants through SPARK research match on SFARI Base.

Dr. Storch reports receiving research funding to his institution from the Ream Foundation, International OCD Foundation, and NIH. He was formerly a consultant for Brainsway and Biohaven Pharmaceuticals in the past 12 months. He owns stock less than $5000 in NView. He receives book royalties from Elsevier, Wiley, Oxford, American Psychological Association, Guildford, Springer, Routledge, and Jessica Kingsley. Dr. Harris reports receiving research funding to her institution from the Health Resources and Services Administration, Ionis Pharmaceuticals, Neuren Pharmaceuticals, the Grace Foundation, the LouLou Foundation, and the CDC/National Fragile X Foundation. She receives a publication royalty from UpToDate.

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Holly K. Harris, Ariel M. Lyons-Warren, Robin P. Goin-Kochel & Leandra N. Berry

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HKH and EAS involved in conceptualizing the secondary data analysis. EAS, LNB, RPG-K, and AGG involved in conceptualizing the original stepped care study. EAS, LNB, RPG-K, and AGG involved in receiving funding. EAS, LNB, RPG-K, and AGG involved in investigation/data collection in the stepped care study. EAS, LNB, and RPG-K involved in overall supervision of the stepped care study. MK involved in data curation. PB involved in secondary data analysis. HKH and EAS involved in drafting the manuscript. HKH, MK, PB, AGG, AML-W, RPG-K, CM, LNB, and EAS involved in reviewing and editing the manuscript. All authors read, reviewed, and approved the final manuscript.

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Harris, H.K., Kook, M., Boedeker, P. et al. The Impact of Cognitive Behavioral Therapy on Sleep Problems in Autistic Children with Co-occurring Anxiety. J Autism Dev Disord (2024). https://doi.org/10.1007/s10803-024-06309-2

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DOI : https://doi.org/10.1007/s10803-024-06309-2

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Maternal antenatal mental health and its associations with perinatal outcomes and the use of healthcare services in children from the NINFEA birth cohort study

Affiliations.

• 1 Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Turin, Italy. [email protected].
• 2 Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Turin, Italy.
• 3 CPO Piemonte, Turin, Italy.
• 4 Department of Mother and Child Health, Azienda USL Toscana Nord Ovest, Pisa, Italy.
• PMID: 38564067
• DOI: 10.1007/s00431-024-05525-3

To investigate the associations between maternal mental health disorders before and during pregnancy and perinatal outcomes and child healthcare utilization between 6 and 18 months of age. Among the 6814 mother-child pairs from the Italian Internet-based NINFEA birth cohort, maternal depression, anxiety, and sleep disorders diagnosed by a physician before and during pregnancy were assessed through self-reported questionnaires completed during pregnancy and 6 months after delivery. Perinatal outcomes (preterm birth, birth weight, small for gestational age, congenital anomalies, and neonatal intensive care unit (NICU)) and children's healthcare utilization (emergency department (ED) visits, hospitalizations, and outpatient visits) were reported by mothers at 6 and 18 months postpartum. We used regression models adjusted for maternal age, education, parity, country of birth, region of delivery, and household income. Maternal mental health disorders were not associated with perinatal outcomes, except for depression, which increased the risk of offspring admission to NICU, and anxiety disorders during pregnancy, which were associated with preterm birth and lower birth weight. Children born to mothers with depression/anxiety disorders before pregnancy, compared to children of mothers without these disorders, had an increased odds of a visit to ED for any reason (odds ratio (OR adj ) = 1.26, 95% confidence interval (CI): 1.02-1.54), of an ED visit resulting in hospitalization (OR adj = 1.75, 95%CI: 1.27-2.42), and of planned hospital admissions (OR adj = 1.55, 95%CI: 1.01-2.40). These associations with healthcare utilization were similar for mental disorders also during pregnancy. The association pattern of maternal sleep disorders with perinatal outcomes and child healthcare utilization resembled that of maternal depression and/or anxiety disorders with these outcomes. Conclusion: Antenatal maternal mental health is a potential risk factor for child-health outcomes and healthcare use. Early maternal mental health interventions may help to promote child health and reduce healthcare costs. What is Known: • Poor maternal mental health affects pregnancy outcomes and child health, and children of mothers with mental health conditions tend to have increased healtcare utilization. • Parents with poor mental health often face challenges in caring for their children and have less parenting self-efficacy, which could potentially lead to frequent medical consultations for minor health issues. What is New: • Maternal pre-pregnancy mental disorders were not associated with preterm birth, low birth weight, SGA, and congenital anomalies, except for depression, which increased the risk of offspring admission to NICU. Anxiety disorders during pregnancy were associated with lower birth weight and an increased odds of preterm birth. • Maternal depression and/or anxiety and sleep disorders, both before and during pregnancy, were associated with an increase in children's healthcare utilization between 6 and 18 months of life.

Keywords: Anxiety disorders; Birth cohort; Children; Depression; Healthcare utilization; Maternal mental health; Perinatal outcomes; Pregnancy; Sleep disorders.

© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

The Benefits of Using a Weighted Blanket

Weighted blankets are heavier than regular blankets. They tend to weigh 5-30 pounds (lbs). The weight provides deep pressure which some people find pleasant and calming.

Some studies suggest that weighted blankets may be beneficial for people with anxiety, autism, or attention-deficit/hyperactivity disorder (ADHD). They are generally thought to enhance sleep, reduce anxiety, and improve overall well-being. However, most studies involve small participant sizes. More research is needed to determine how weighted blankets might benefit different populations.

Weighted blankets should only be used by people who can move or remove them to avoid suffocating or becoming trapped. Most manufacturers state that children under 50 pounds or the age of four and people with certain medical conditions should not use them. An adult should always supervise children who use weighted blankets.

How Does a Weighted Blanket Work?

A weighted blanket consists of a removable cover and an insert filled with materials like glass or plastic beads or pellets. It applies deep pressure, or deep touch pressure (DTP), as does hugging, holding, swaddling, and stroking. This pressure offers several potential benefits, including reducing stress and anxiety , improving mood, and supporting quality sleep.

Continual deep pressure provides ongoing sensory input. This can be effective for people with difficulty processing sensory information. With sensory processing sensitivity (SPS) and sensory processing disorder (SPD), the brain has a heightened sensitivity to stimuli. Using a weighted blanket seems to help the brain regulate sensory information. It turns on the parasympathetic nervous system, which allows you to rest and relax.

More research is needed to confirm the possible benefits of weighted blankets. 

1. May Reduce Stress

The pressure that weighted blankets place on your body may increase serotonin . This hormone can promote calmness and improve your mood. The deep pressure may also lower your levels of cortisol , a hormone released during physical or mental stress. Cortisol can keep your body on high alert, so reducing it can help relieve feelings of stress and anxiety.

2. May Promote Sleep

Reducing your cortisol levels may benefit your sleep because it plays a part in your sleep-wake cycle . Cortisol is typically highest early in the morning and lowest at night. High levels of cortisol might make it harder to sleep.

Weighted blankets may also increase your levels of melatonin , another hormone involved in the sleep-wake cycle. Your body produces melatonin in response to darkness, which helps prepare your body for sleep.

In short, weighted blankets may set the stage for better sleep by lowering cortisol levels and increasing melatonin levels.

3. May Reduce Chronic Pain

A 2022 trial of 94 adults with chronic pain suggested that weighted blankets reduced broad perceptions of chronic pain. This was especially true for people with high levels of anxiety. The effect was more significant for blankets weighing about 15 pounds than those that weighed five pounds. The study authors suggest that the pleasant sensation of weighted blankets may distract people from chronic pain.

4. May Improve Certain Conditions

There isn’t enough research to confirm the benefits of weighted blankets. However, some research suggests that weighted blankets may be useful for people with certain conditions. These include anxiety, sleep disorders, autism spectrum disorders, and attention-deficit/hyperactivity disorder (ADHD).

Weighted blankets may help alleviate anxiety . Several studies found that mental hospital patients reported reduced anxiety after using weighted blankets. A small 2023 study showed a similar benefit among trauma patients with acute injuries.

Sleep Disorders

A small study of four participants with sensory sensitivity and insomnia found that all patients experienced improved sleep quality after using weighted blankets. Three patients slept longer than they did previously.

Likewise, a 2020 trial of 120 patients with mental health disorders found that weighted blankets reduced insomnia symptoms. They also reduced symptoms of daytime fatigue.

Autism Spectrum Disorders (ASD)

Up to 40-80% of children and teenagers with autism have sleep challenges. Research suggests that weighted blankets might help.

One 2023 study found that using a weighted blanket helped autistic participants fall and stay asleep. It helped them relax and was associated with a better sleep routine.

A 2014 trial did not find these benefits. However, it found that many autistic children preferred weighted blankets to non-weighted ones.

Attention-Deficit Hyperactivity Disorder (ADHD)

Sleep challenges are common among people with ADHD, affecting up to 50% of children and 80% of adults. Not getting enough sleep can affect all aspects of a person's life and worsen symptoms of ADHD.

Some research suggests weighted blankets may be useful. A 2023 study found that weighted blankets are popular among people with ADHD and may aid in sleep and relaxation. They may also help people with ADHD develop a better routine around bedtime and waking up.

A 2021 study surveyed 24 parents of children with ADHD. Many parents reported improvements in sleep after their children slept with weighted blankets for four months. They said their children fell asleep faster, stayed asleep longer, and had more regular sleep routines . Parents also reported improvements in their children's participation in everyday life.

A 2023 trial mirrored some of these results. It suggested that weighted blankets helped children with ADHD sleep longer and more efficiently. Other research suggests that weighted blankets may help some children with ADHD feel calm and safe.

How To Use a Weighted Blanket

The general recommendation is to use a weighted blanket around 10% of your body weight. A range of 8-12% may also work. Reach out to a healthcare provider about which weight might be best, especially if you have a medical condition or are shopping for a child.

You may want to begin by using the weighted blanket for short periods (such as naps) as your body adjusts. When you start using it at night, it may be best to begin by using the blanket over half of your body. You can also use a regular blanket or flat sheet to keep warm. After about a week, you can move up the blanket gradually—a little more each night. Don't bring the blanket past your shoulders.

It may take a few weeks to adjust fully to the weight. After that, you can use weighted blankets for as long as you feel comfortable.

Are Weighted Blankets Safe?

Weighted blankets may be beneficial for some people, but they aren’t for everyone. People should only use weighted blankets if they can move or remove the blanket when necessary. Otherwise, there is a risk of suffocating or becoming trapped.

Reach out to a healthcare provider before getting a weighted blanket for a child. The American Academy of Pediatrics recommends against the use of any weighted products (including blankets) on or near sleeping infants.

Beyond that, lower age limits vary. Most manufacturers advise against using weighted blankets on any child under the age of 2, and some suggest waiting until a child is 4 or older. They cite the risks of becoming trapped, overheating, suffocating, and sudden infant death syndrome (SIDS).

Weighted blankets should also be avoided for children under 50 pounds. Always supervise your young child if they're using or playing with a weighted blanket. Don't let the blanket wrap around them tightly or cover their face.

Health Conditions

People with sleep apnea or breathing problems might find weighted blankets uncomfortable, as they may make it harder to breathe. Contact a healthcare provider before using a weighted blanket if you have any medical conditions, including:

• Circulatory issues
• Hypotension (low blood pressure)
• Type 2 diabetes
• Claustrophobia (fear of small or confined spaces)

A Quick Review

Weighted blankets are heavy blankets that may weigh up to 30 pounds. They apply deep pressure, which can feel pleasant and calming.

There isn’t enough evidence to draw conclusions on the benefits of weighted blankets. However, some studies suggest they may improve sleep and relieve stress, anxiety, and chronic pain. They may also benefit people with sleep disorders, anxiety disorders, autism, or ADHD.

Contact a healthcare provider before giving a weighted blanket to a child. Weighted blankets shouldn't be given to children under the age of 4 or below 50 pounds. It's also best to consult a healthcare provider before using weighted blankets if you have any health conditions.

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