Separation Anxiety Disorder

Developmentally inappropriate or excessive anxiety or fear upon separation from attachment figures (usually a parent or primary caregiver) or from home for a duration of at least 4 weeks is the core feature of SAD as defined by both the DSM-5 and the ICD-10 diagnostic criteria (APA, 2013; WHO, 1992). Children with SAD may experience a variety of behavioral (e.g., clinging to attachment figure, crying) and somatic symptoms (e.g., muscle aches, headaches) upon separation from or in anticipation of separation from the attachment figure. Children with SAD experience intrusive worries that something might happen to the attachment figure or to the child him-/herself. Furthermore, a child with SAD may be reluctant to sleep alone or to sleep away from home. School refusal is associated frequently with SAD and can be one of the most debilitating symptoms for both the child and the family. Moreover, comorbidity of SAD with other anxiety disorders and with depression is common (Black, 1995; Last, Hersen, & Kazdin, 1987).

Of note, there is a good deal of variation across cultures regarding expectations for separation; thus, the severity of clinical symptoms that warrant a diagnosis of SAD may vary widely depending on the child’s contextual environment. Thus, it is important to assess for and take into account cultural norms regarding separation when considering a diagnosis of SAD.

Generalized Anxiety Disorder

The core feature of GAD is excessive worrying related to a number of events or activities (e.g., world events) that lasts for a period of six months or more (APA, 2013; WHO, 1992). This worry is difficult to control or stop; children with GAD may experience difficulty concentrating on schoolwork or social interactions because of their focus on their worries. Additionally, the worry is accompanied by somatic complaints and distress. As with SAD, children with GAD have a high rate of concurrent mental health disorders (Costello, Egger, & Angold, 2005).

Social Anxiety Disorder (Social Phobia)

Social anxiety disorder or social phobia is characterized by an excessive fear of negative evaluation by others. Often this extreme fear of judgment and evaluation is in situations with unfamiliar people or situations that could possibly result in scrutiny. The anxiety must be present in a variety of interactions (e.g., with peers, not just in interactions with adults) for a diagnosis of SOC to be made. Typically, children with social anxiety avoid social interactions to the extent that normal daily functioning can be greatly impaired (Stein & Gorman, 2001). The onset of SOC generally occurs during adolescence (approximately 13 years of age, on average); however, SOC can become evident during early childhood (Beidel, Turner, & Morris, 1999). As with other anxiety disorders, children with SOC often present with comorbid disorders; moreover, SOC in youth is associated with increased risk of substance abuse disorders later in life (Buckner et al., 2008).

Specific/Simple Phobia

Specific (simple) phobia is defined by excessive and marked fear in response to encountering or anticipating an object or situation (e.g., heights, small places, animals) (APA, 1994). The fear causes distress and interference in the child’s routine, and the feared stimulus is generally avoided. Although adults often realize that their fears are excessive and unreasonable, this may not always be the case for children. It is estimated that SPs occur in about 8% of children (Kim et al., 2010). Again, children with SPs often present with comorbid disorders (Kim et al., 2010).

Psychoeducation and Emotion Education

Psychoeducation efforts are aimed at helping the child and his/her family understand the treatment rationale and lay the foundation for the skills that are the focus of later sessions. Children and their families are given basic information regarding anxiety and are introduced to the CBT model and specifically the interaction among thoughts, feelings, and behavior. Maintaining factors of anxiety are discussed, with a particular focus on avoidance and accommodation. This may be the first time that the family begins to consider that accommodation of anxious behavior and/or avoidance of anxiety-provoking stimuli are not necessary reactions to anxiety. Therapists focus on helping families understand that the experience of anxiety is not, in and of itself, dangerous and that anxiety does not spiral out of control and continue indefinitely, as many people believe.

Psychoeducation also typically involves helping children to recognize and distinguish feelings and increase their awareness of their emotions. Emotion education can help children to identify the specific situations that lead to anxiety. This process can set the stage for later efforts at using coping strategies and monitoring anxious cognitions.

Problem Solving

Problem-solving methods are taught and practiced in order to help children identify new methods for addressing anxiety-provoking situations. Children are taught to use a step-by-step process that includes finding multiple solutions to a problem, examining the costs and benefits of each, and implementing the preferred solution. Given that research suggests that children with anxiety disorders prefer avoidant ways to cope with anxiety and that this behavior may be encouraged by parents (Dadds, Marrett, & Rapee, 1996), problem solving can serve the important function of allowing children to recognize that other approach-oriented options are available and to examine the pros and cons of avoidant versus approach behaviors.

Cognitive Restructuring

Cognitive restructuring helps children identify and replace maladaptive thoughts and beliefs with more adaptive thoughts and beliefs. Learning to think more realistically is an important strategy for helping children overcome anxiety. In order for children to change their thoughts, it is important for them to first understand the relationship among thoughts, feelings, and behaviors. That is, it is important for children to understand that their feelings and emotions are not directly caused by the events and situations that occur but instead by the way events are thought about and interpreted. Such an approach may also allow anxious children to begin to feel more control over their emotions.

Cognitive restructuring efforts often focus on two common errors made by children with anxiety disorders: overestimation of the probability of threat or negative outcomes and overestimation of the negative consequences of an event, should it occur. For example, a little boy who experiences social anxiety when starting a conversation with peers may be taught to examine and modify his automatic thought that other children will laugh at him if he says something wrong when joining a group, or he may be encouraged to modify his beliefs about how bad it would be if the other children did indeed laugh at him.

Given that most anxious children think in these unrealistic ways, it is important for children to recognize their thought patterns and identify their dysfunctional beliefs so they might begin to develop more adaptive ways of thinking. However, the concept of cognitive restructuring and the process of actually changing thoughts is difficult, even for adults. Therefore, when working with children, cognitive restructuring often is introduced as a game in which children are encouraged to become detectives to first find anxiety-provoking thoughts and then to find various clues to determine whether their anxious thought is accurate.

Exposure

Most anxious children have developed ways to avoid the situations that are frightening for them. Therefore, they never allow themselves the opportunity to learn that neither the feared situation nor the experience of anxiety is dangerous. As such, a central component of almost all evidence-based approaches to the treatment of anxiety disorders in children is some form of exposure and response prevention. Often children are exposed to feared stimuli in a graduated process, using a fear hierarchy. Children often are encouraged to conceptualize the hierarchy as a stepladder or hill that they are climbing, taking small steps in order to climb the entire way. Exposure can be in vivo or imaginal, but often a combination of the two is used.

Relapse Prevention

Treatment usually terminates as children become more adept at using the skills taught and generalizing these skills to other settings. As such, concluding sessions often focus on consolidation and assessment of skills. Many times relapse prevention is the focus of the final sessions. Reoccurrence of anxiety symptoms can occur for several reasons (see Bouton, Woods, Moody, Sunsay, & Garcia-Gutierrez, 2006); when anxiety does reoccur, it is important for children and the parent to know that they have acquired the necessary skills to prevent the anxiety from becoming impairing and out of control. Relapse prevention focuses on combining the skills learned during treatment and applying them with decreased reliance on the therapist. During relapse prevention, situations are identified that potentially could be problematic in the future, and children and their family are asked to identify skills that could help them in managing these situations. The therapist must assess whether each child and family has the ability to use the skills independently and to generalize the skills to novel problems. Treatment ends when these conditions are met, not when anxiety is absent or when stressful situations cease, as anxiety and potential stressors are considered normal experiences that are not inherently dangerous.

Generalized Anxiety Disorder, Separation Anxiety Disorder, and Social Anxiety Disorder

Randomized controlled trials (RCTs) provide strong evidence for the use of CBT for the treatment of GAD, SAD, and SOC for youth as young as 3 years of age (e.g., Kendall, 1994; Minde, Roy, Bezonsky, & Hashemi, 2010; Silverman, Kurtines, Ginsburg, Weems, Lumpkin, et al., 1999). More specifically, individual cognitive behavioral therapy (ICBT), group cognitive therapy (GCBT) with parents, and group cognitive therapy (GCBT) without parents all have been shown to be efficacious. Overall, studies indicate that ICBT and GCBT are comparable (e.g., Flannery-Schroeder & Kendall, 2000), as is CBT with or without parent involvement (see the Parent Involvement section further on). Remission rates, defined as youth diagnosis free at posttreatment, are as high as 65% to 70% (Barrett, Dadds, & Rapee, 1996; Flannery-Schroeder & Kendall, 2000). Specific manualized evidence-based treatments have been developed for GAD, SAD, and SOC in youth. One of the most widely researched, the Coping Cat program (Kendall, 1994), a manual for use with children 6 to 13 years of age, addresses impairing and distressing symptoms related to anxiety using CBT as described earlier. Included in the program is a therapist manual and child workbook. Early trials have shown the Coping Cat program to be effective compared to a wait list, with approximately 53% of children free of their primary diagnosis at the end of treatment (Kendall et al., 1997). Additionally, children treated with the Coping Cat program show significant improvement in symptomatology based on parent and child reports, and multiple long-term follow-up studies provide evidence that positive outcomes are maintained across time. For example, at an average of 3.35 years after the conclusion of treatment, anxious youth maintained treatment gains such as positive changes in coping and decreased levels of distress (Kendall & Southam-Gerow, 1996). Similarly, adolescents who had completed the Coping Cat program on average 7.4 years earlier also maintained positive treatment gains, with 81% of the adolescents no longer carrying their initial anxiety diagnosis, based on parents’ interview (Kendall, Safford, Flannery-Schroeder, & Webb, 2004). Importantly, this suggests that the benefits of CBT treatment are maintained across developmental periods. In addition, the Coping Cat program has been adapted and extended in other countries. For example, in Australia, studies suggest that treatment programs stemming from the program provide similar positive outcomes (e.g., Barrett, 1998).

Specific Phobia

Research also supports CBT for the treatment of SPs in youth (Davis, Ollendick, & Öst, 2009, 2012; Ollendick et al., 2009). More specifically, evidence suggests that exposure to the feared stimulus is crucial in the treatment of SP in children (Cornwall, Spence, & Schotte, 1996). For example, Cornwall and colleagues found emotive imagery to be superior to a wait-list control for the treatment of SPs. More specifically, results revealed that children who received emotive imagery tolerated a dark room longer compared to children in the wait-list group, and parents of children in the emotive imagery group reported their child experienced an overall reduction of the fear of darkness, with outcomes maintained at 3-month follow-up (Cornwall et al., 1996).

In another study, children age 6 to 16 with a phobic disorder were assigned to exposure with self-control, exposure plus contingency management, or education support. Eighty-eight percent of children who received exposure therapy with self-control were diagnosis free at posttreament as compared to 56% of the youth who received education support (Silverman, Kurtines, Ginsburg, Weems, Rabian, et al., 1999). Further, positive treatment gains were maintained at 3-, 6-, and 12-month follow-up assessments (Silverman, Kurtines, Ginsburg, Weems, Rabian, et al., 1999). Interestingly, more recent research suggests that treatment for SPs can be delivered effectively in a single, intensive session (see adaptions and modifications as well as Ollendick et al., 2009).

In sum, CBT has been shown to be effective for children with a variety of anxiety disorders. Although CBT can be delivered in a variety of formats depending on the specific anxiety disorder, numerous randomized controlled studies suggest that CBT can be efficacious in both the short and the long term.

Single-Session Treatment

Ollendick and colleagues have found support for an intensive version of CBT for youth with SPs (Davis et al., 2009; Ollendick et al., 2009). More specifically, results from an RCT conducted in the United States and Sweden show that a single session, lasting up to 3 hours and focusing on graduated exposure with the aim of modifying catastrophic conditions, can be effective for a sizable proportion of youth with clinically significant SPs (Ollendick et al., 2009). Although there was some evidence from this trial that girls’ long-term outcome was superior to boys’, in general the treatment seemed to be effective across a range of sociodemographic variables as well as comorbid conditions (Ollendick, Öst, Reuterskiöld, & Costa, 2010). Moreover, dropout was nonexistent (since there was only one prolonged session), so this may be an especially attractive option for families that may not have the resources to attend sessions regularly over 4 to 6 months. Whether intensive treatment programs such as this can be used with children with other anxiety disorders awaits further research.

Alternative Methods of Treatment Delivery

Parent-directed bibliotherapy, in which parents are taught to implement a CBT treatment with their child, has been shown to be effective (Rapee, Abbott, & Lyneham, 2006); however, studies suggest that many families need support in the form of therapist contact in order to stay engaged with and benefit from such treatments (Lyneham & Rapee, 2006). Of note, this is not to say that all forms of self-help books that address anxiety in youth would be expected to be efficacious; the book used in these trials was based on a treatment approach with empirical support.

Similarly, Kendall and colleagues have examined computer-assisted treatment delivery as a method for disseminating the empirically supported Coping Cat treatment. In this program, children first work through six computerized sessions to learn CBT skills such as problem solving and relaxation, then they continue to use the computerized treatment package with assistance from a therapist to complete tailored exposure sessions. Research suggests that this method of delivery is better than an education support condition and produces outcomes similar to standard CBT with about half of the investment of therapist time (Khanna & Kendall, 2010).

Community Intervention and Prevention Efforts

Several studies have shown some support for the use of CBT strategies either as a universal prevention program or for use with children who evidence high levels of anxiety symptoms but not necessarily a full-blown anxiety disorder (Aune & Stiles, 2009; Essau, Conradt, Sasagawa, & Ollendick, 2012; Neil & Christensen, 2009; Simon, Dirksen, Bögels, & Bodden, 2012; Stopa, Barrett, & Golingi, 2010). These interventions often use strategies similar to those found effective in trials of diagnosed youth but often with fewer sessions. Typically these programs are delivered in a group format and by classroom teachers. Studies generally have shown a reduction in anxiety over time with such interventions, although some have found this reduction to be similar to that found in control conditions; additionally, further research is needed to determine whether such interventions for high-risk youth prevent the development of later anxiety disorders.