This page discusses the following common child and adolescent anxiety disorders, treatment, and information for parents/guardians: obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, selective mutism, specific phobia, social phobia, separation anxiety, Tourette's Syndrome, & Tic Disorders


Obsessive-compulsive disorder typically begins during adolescence or early childhood and at least one third of the cases of adult OCD began in childhood. Early-onset obsessive-compulsive disorder is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3% and is seen in as many as 1 in 200 children and adolescents. OCD affects more often boys who also have a diagnosis of attention deficit hyperactivity disorder. Comorbid mental disturbances are present in as many as 70% of patients with OCD. When two diagnoses occur in the same individual, they’re referred to as “comorbid” disorders. It is important to get a thorough assessment evaluated on your child or adolescent to address symptoms and rule out disorders for proper treatment.  Research has shown that if left untreated, children with anxiety disorders are at higher risk to perform poorly in school, to have less developed social skills, and to be more vulnerable to substance abuse. Stressful life events, such as starting school, moving, or the loss of a parent, can trigger the onset of an anxiety disorder, but a specific stressor need not be the antecedent to the development of a disorder. Children may want to hide their feelings, obsessions, or compulsions because they are ashamed or embarrassed about their symptoms. Children may also be unaware or unwilling to admit that their behavior may indicate symptoms of a disorder.  ​


Common Obsessions:
Fear of harm to self or family
Need to have things lined up
Fear of germs or diseases 
Need for perfectionism
Fear of losing something valuable 
Religion
Intrusive thoughts
Doubt
Sex
Loss
Aggression

Common Compulsive Behaviors:
Cleaning & washing
Counting
Hoarding
Arranging
Checking things over & over
Need to ask, tell, or confess
Repeating
Ordering or arranging
Avoiding
Seeking reassurance
Touching

What other things do children with OCD do?
Children and teens with OCD often put much effort in to trying to avoid anything that might trigger their OCD.
Reassurance seeking from their family is very common behavior among children and teenagers with OCD. 
Children and teens get their family members involved in the rituals because they are so anxious about their compulsions. 

When your son or daughter has been diagnosed  with OCD, what can you do as a parent to help? 
Understand the illness
Listen to the child’s feelings
Plan for transitions
Adjust expectations until symptoms improve
Praise the child’s efforts
Discuss things as a family
Understand parental limits
Understand the importance of effective communication with schools

Negative comments and criticism make OCD worse. Stay calm and keep a supportive network, because this helps improve the outcome of treatment. Do not tell the person to simply stop the behavior or do not show anger by the compulsions. Instead, praise successful attempts. 

Flexibility and a supportive environment are essential for a student with OCD to be successful in school. As a parent, you can be active in the school setting and become knowledgeable about what is best for your child or teen. At school, a child may have difficulty concentrating, experience social isolation, have low self-esteem, engage in behavior problems, have ADHD or other  learning disorders and cognitive problems that may be overlooked. Please review the following links below for information on OCD and children. 


​National Institute of Mental Health
Evidence-Based Assessment of Child Obsessive Compulsive Disorder: Recommendations for Clinical Practice and Treatment Research
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847172/

PANDAS Fact Sheet
http://pandasnetwork.org/wp-content/uploads/2016/04/2015-PNETWORK-fact.pdf

National Institute of Mental Health
PANDAS: Fact Sheet about Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections 
https://www.nimh.nih.gov/health/publications/pandas/index.shtml



What should parents look for in infants and toddlers?
Common fears among infants include loud noises, being dropped, and later, normal separation anxiety. Toddlers typically experience fear of imaginary creatures (monsters) and darkness. From age 5 to 6 years, children experience worries about physical well-being (eg, injury, kidnapping) and later, fears of natural events (storms) develop. 

Researchers also suggest watching for signs of anxiety disorders when children are between the ages of 6 and 8. At this age, children grow less afraid of the dark and imaginary creatures and more anxious about school performance and social relationships. High levels of anxiety in a child aged 6 to 8, therefore, may be a warning sign that the child may develop anxiety disorder later.

What should parents look for when children attend school?
School-aged children worry about school performance, behavioral competence, rejection by peers, health, and illness. Children may complain of headaches, abdominal complaints, and muscle tension. They may throw tantrums about attending school. It is especially important for children and teens to have a consistent bedtime that doesn’t dramatically change on the weekends. School aged children need between 10-12 hours of sleep and teens require 8 ½ to 9 ½ hours. It is important that children that suffer from OCD who are perfectionists to have an established routine and that they are not overwhelmed with activities. Parents, at times, may need to set limits and make getting a good night’s rest a priority.

Anxiety disorders can be long-lasting and interfere greatly with a child’s life. If not treated early, anxiety disorders can lead to:
Missed school days or an inability to finish school
Low self-esteem
Impaired relations with peers
Anxiety disorder in adulthood and alcohol or other drug abuse

What should parents look for in adolescence?
In adolescence, worries about social competence, social evaluation, and psychological well-being are prominent. 

If not treated early, anxiety disorders can lead to:
Missed school days or an inability to finish school
Low self-esteem
Impaired relations with peers
Anxiety disorder in adulthood and alcohol or other drug abuse

What is the best treatment for children with anxiety disorders?
Exposure-based cognitive behavior therapy has empirical support from wait-list-controlled studies for the treatment of childhood anxiety disorders. 

There are several components of CBT for childhood anxiety disorders: 
1. Psychoeducation with child and parents about anxiety and CBT for anxiety disorders
2. Somatic management skills training: self-monitoring, muscle relaxation, diaphragmatic breathing, relaxing imagery
3. Cognitive restructuring: challenging negative thoughts and expectations, learning positive self-talk
4. Practicing problem solving: generate several potential solutions for anticipated challenges and generate a realistic action plan ahead of time
5. Exposure methods: imaginal and live exposure with gradual desensitization to feared stimuli

Psychoeducation with child and parents about anxiety and CBT for anxiety disorders
Parents are also educated on how to provide consistent and frequent positive reinforcement for the child’s efforts and successes. This increases the child’s motivation to attempt exposures that initially increase anxiety and discomfort levels. Over the course of treatment, learning to self-reward is emphasized. Parents learn anxiety-management skills so they can function to facilitate and reinforce this at home. If a parent is anxious, it is imperative that there is parental involvement in the treatment process. Parents need to model the behavior and demonstrate parenting skills that decrease avoiding coping and encourage self-efficacy in the child for success.

Somatic management skills training: self-monitoring, muscle relaxation, diaphragmatic breathing, relaxing imagery
These skills target the physical symptoms of anxiety. For example, children with panic disorder need education about the physiological processes that lead to physical sensations and coping strategies. Interoceptive exposure can reduce worry about future panic attacks. 

Cognitive restructuring: challenging negative thoughts and expectations, learning positive self-talk
Practicing problem solving: generate several potential solutions for anticipated challenges and generate a realistic action plan ahead of time

Exposure methods: imaginal and live exposure with gradual desensitization to feared stimuli
Children need to develop a fear of hierarchy with relaxation skills and gradually move up to higher anxiety provoking fears. Modifications may include the use of real life desensitization programs, narrative stories, live modeling, and the child having physical contact with the phobic object or situation. For example, children with social phobia exposures may include an emphasis on social skills training and increased social opportunities. Examples of exposures may also include ordering at a restaurant or purchasing something at a store, initiating a conversation, reading out loud in front of people, or giving a speech. 

Relapse prevention plans: booster sessions and coordination with parents and school
Parents and school staff need to take an active role in treatment to prevent the child’s refusal to go to school. Tantrums, irritability, and physical resistance related to anticipation of separation is common in children with separation anxiety disorder. There is also evidence to support behavioral interventions for selective mutism. Parents and other people are encouraged not to speak for the child and efforts of nonverbal communication with pointing and participating are positively reinforced and over time children begin mouthing words gradually increasing to whispering, speaking in a soft voice and speaking loudly. The child learns to manage his/her anxiety through standard cognitive behavior strategies. Homework assignments for children to work on may include reading with a known peer outside of class or speaking to teacher at recess. 


Selective Mutism is a psychiatric disorder most commonly found in children, characterized by a persistent failure to speak in select settings which continues for more than one month. Selective mutism appears to be related to severe anxiety, shyness, and social anxiety. 

Symptoms of this disorder may include:
Ability to speak at home with family
Failure to speak in certain social situations or reluctance to speak in some settings
Fear of people
Shyness
Associated behaviors include: no eye contact, no facial expression, or nervous fidgeting when confronted with general expectations in social situations

Treatment:
Treatment includes behavioral therapy using desensitization exposures and positive reinforcement that build coping skills and help patients become more comfortable in situations that cause anxiety. The two factors in determining when treatment is necessary are age and severity of the case. For those experiencing severe forms of Selective Mutism, immediate intervention is advised, because the symptoms can increase. A younger child has a better chance at improving if treated. If mutism persists more than 2 months and if there are no verbal responses at all, treatment should begin immediately. 


Separation Anxiety Disorder is a condition in which a child becomes fearful and nervous when away from home or separated by a loved one. The child may have separation anxiety disorder when this fear occurs in a child over the age of 6 years and if it is excessive fear that lasts longer than four weeks. Children whose parents are over-protective may be more prone to separation anxiety. Separation anxiety affects approximately 4%-5% of children in the U.S. ages 7-11 years. 
  
Symptoms of this disorder may include:
Unrealistic and lasting worry that something bad will happen to the parent or child while away
Refusal to go to school
Complaints of headaches & stomach aches on school days
Repeated temper tantrums 
Refusal to go to sleep without parent near by
Fear of being alone
Bed wetting 

Treatment:
The goals of treatment include reducing anxiety in the child, developing a sense of security in the child and the caregivers, and educating the child and family/caregivers about the need for natural separations. A type of therapy called cognitive-behavioral therapy works to reshape the child's thinking (cognition) so that the child's behavior becomes more appropriate. Family therapy also may help teach the family about the disorder and help family members better support the child during periods of anxiety. Treatment options that may be used include psychotherapy to help the child tolerate being separated from the caregiver without the separation causing distress or interfering with function. Antidepressants or other anti-anxiety medications may be used to treat severe cases of separation anxiety disorder.


Generalized Anxiety Disorder is characterized by chronic anxiety, constant worry and tension, even when their is little or nothing to provoke it. They can not seem to forget their concerns and it can interfere with their daily functioning.

Symptoms of this disorder may include:
Fatigue
Headaches
Muscle tension and aches
Difficulty swallowing
Trembling or twitching
Irritability
Sweating, palpitations, or hot flashes
Difficulty concentrating or controlling worry
Excess anxiety that is disproportionate 
Sleep disturbance
Depression and substance abuse may occur with an anxiety disorder

Treatment:
Cognitive-behavioral therapy involves education, monitoring, physical control strategies, cognitive control strategies, and behavioral strategies.

Panic Disorder often begins during adolescence, although it may start during childhood, and sometimes runs in the family. If not recognized and treated, panic disorder and its complications can be devastating. A panic attack is characterized by discrete period of intense fear or discomfort in which at least four from a list of thirteen standard symptoms develop abruptly and reach a peak within 10 minutes. Panic disorder is a condition in which recurrent, unexpected panic attacks and long periods in constant fear of another attack occur. Panic disorder often starts in late teens or early adulthood and affects more women then men. Panic disorder is highly treatable, however left untreated, panic attacks and panic disorder gets worse and can result in severe complications that affect almost every area of life. One can develop specific phobias, avoidance of social situations, problems at work or school, depression, increased risk of suicide or suicidal thoughts, alcohol or substance abuse, and or financial problems. Panic disorder affects about 2.4 million adult Americans. 

Symptoms of a panic attack may include:                                 
A feeling of imminent danger or doom
The need to escape
Heart palpitations
Sweating
Trembling
Shortness of breath or a smothering feeling
A feeling of choking or trouble swallowing
Chest pain or discomfort    
Nausea or abdominal discomfort
Dizziness or lightheadedness
A sense of things being unreal, depersonalization
A fear of losing control or "going crazy"
A fear of dying
Tingling sensation
Chills or heat flush

Treatment:
Cognitive Behavioral Therapy is the  most effective and well-documented psychotherapy for panic disorder. Approximately 80% of patients respond to CBT for panic disorder and the effects appear to be more robust and more long-lasting than medication treatment alone. The main techniques used in CBT for panic disorder are relaxation training, thought restructuring, and gradual exposures. 

Panic Disorder and Children or Teenagers:
Panic disorder can look different in young people than adults because children tend to report the physical symptoms instead of the psychological symptoms accompanying panic attacks. If left untreated, panic disorder can lead to significant worry or limitations in other areas of the child’s life. Peer relationships, family relationships, or school functioning may suffer and comorbid depression may develop. Reluctance to go to school or engage in other age-appropriate activities may result from panic disorder. Adolescents with panic disorder may self-medicate, leading to substance abuse.

What Does Panic Disorder Look Like in Children and Adolescents? (Symptoms at home, school, & at the doctor’s office/Interventions at home and at school)
http://www2.massgeneral.org/schoolpsychiatry/info_panicdisorder.asp

Social Phobia, is an anxiety disorder involving intense fear of certain social situations in which the person is afraid of being scrutinized, judged, or embarrassed in public. Social anxiety disorder usually starts during the child or teen years (around age 13) and usually begins in childhood or adolescence. Children are prone to clinging behavior, tantrums, and even mutism. Social anxiety disorder affects over 7% of the population at any given time.


Specific Phobia is a lasting and unreasonable fear caused by the presence or thought of a specific object or situation that usually poses little or no actual danger. Exposure to the object or situation brings about an immediate reaction and causes intense anxiety. The stress of this fear can interfere with the person’s ability to function. 

Examples of specific phobias include: 
Animal
Situational such as flying, driving, being in closed places, or going over bridges
Natural environment such as storms, heights, or water
Blood-injection-injury such as fear of being injured or injections
Other phobias such as fear of falling down or fear of costumed characters

Symptoms of this disorder may include:
Excessive or irrational fear of a specific object or situation
Physical symptoms of anxiety or a panic attack: nausea, diarrhea, sweating, trembling, shortness of breath, feeling dizzy, or feeling like you are choking
Anticipatory anxiety in which you feel nervous ahead of time 


Tourette’s Syndrome is one of several tic disorders that are classified either by their type (motor or phonic tic) or their duration (transient or chronic). Tourette syndrome is a neuropsychiatric disorder characterized by repetitive movements (motor tics) and sounds (vocal tics). TS is generally lifelong, though specific tics tend to come and go, and severity changes over time. The diagnosis of a transient tic is made if the tics are present for less than 12 months. If the tics persist for more than 12 months, they are classified as chronic tic disorder. If both vocal and motor tics are present for longer than one year, the diagnosis of Tourette syndrome is appropriate.


Tic disorders commonly begin in childhood, with the typical age of onset between 5 and 7 years. Most cases begin with simple tics such as eye blinking, or facial movements, and may progress in a caudal fashion to include tics of the head, neck, shoulders, arms, legs, and abdomen. More complex tics may develop over time, and might include hopping or turning, touching or tapping, or multiple tics occurring in rapid succession, such as arm thrusting, head jerk and loud vocalization. The variety of complex tics is myriad and can consist of any movement that an individual might normally make. Vocal tics usually begin one or two years after the onset of the motor tics and often consist of throat clearing, humming or grunting. More complex vocal tics include the repetition of words or parts of words, swearing (coprolalia), or the repetition of what others around are saying (echolalia). These more complex vocal tics occur in only the minority of cases (approximately 20%). Transient tics are quite common in childhood and can affect up to 10% of school age children. The prevalence of chronic tic disorders, including TS, is between 2 and 4%. Once presumed to be rare, the prevalence of Tourette syndrome is now estimated to range between 1 to 10 per 1000 in school age children. 
Scahill L, Sukhodolsky D, Williams S, Leckman J. The public health importance of tics and tic disorders. Adv Neurology. 2005;96:240–248

Treatment:
The currently favored treatment approaches, both pharmacological and psychological, for OCD vs. T/TS also differ. For OCD the psychological treatments of choice are the cognitive-behavior therapy (CBT) techniques of exposure and response prevention (ERP) and cognitive therapy (CT), while pharmacological treatment favors the serotonin reuptake inhibiting family of antidepressants, selective and non-selective (SSRIs, SRIs) and a variety of augmenting medications. Tics/TS, on the other hand, tend to be treated by the CBT techniques of contingency management, relaxation training, and habit-reversal training (HRT). Medications favored for treatment of T/TS are standard neuroleptics (e.g., haloperidol, pimozide)) and atypical neuroleptics (e.g., risperidone, olanzapine) and alpha-2 agonists (e.g., clonodine, guanfacine). OCD and T/TS have also been viewed as distinctly different entities on the basis of differing courses as well as presumed etiologies. Yet despite the distinctions outlined above, there is substantial evidence that OCD and T/TS overlap in ways that suggest a much closer relationship. The frequent concurrence of symptoms of both disorders in the same individual is one strong clue. Up to 60% of TS sufferers have been reported to have OCD symptoms, 50% of children with OCD are reported to have had tics, and 15% met criteria for TS. Also, evidence from family studies and lines of genetic research suggest that the disorders are etiologically linked. OCD and TS exist as separate entities according to the current Diagnostic and Statistical Manual of Mental Disorders (4th Edition) – DSM-IV. OCD is classified as an anxiety disorder while tic disorders, including TS, are among “Disorders Usually First Diagnosed in Childhood.” 

Resource: http://www.ocfoundation.org/EO_TS.aspx




​Children & Anxiety