Treatment and Outcomes for Anxiety Disorders Among Children and Adolescents: A Review of Coping Strategies and Parental Behaviors

CHILD AND ADOLESCENT DISORDERS (TD BENTON, SECTION EDITOR)

Treatment and Outcomes for Anxiety DisordersAmong Children and Adolescents: A Review of CopingStrategies and Parental Behaviors

David Simpson & Liza Suarez & Sucheta Connolly

Published online: 14 January 2012# Springer Science+Business Media, LLC 2012

Abstract This article reviews the current literature on thetreatment of anxiety disorders in children and adolescentsand describes the factors that are essential to address in treat-ment. Coping deficits and parental behaviors are highlightedas factors that contribute to anxiety in youth. Interventions foranxious youth are described, with particular emphasis oncognitive-behavioral therapy for anxiety disorders. Finally, areview of the longitudinal course of anxiety and suggestionsfor future directions in treatment and research are provided.

Keywords Childhood anxiety disorders . Treatment .

Adolescents . Cognitive-behavioral therapy . CBT. Copingdeficits . Parental behaviors . Exposure . Coping strategies

Introduction

Anxiety disorders are the most common psychiatric conditionamong children and adolescents, with lifetime prevalencerates ranging from 2.6% to 20% [1, 2]. Despite the availabilityof state-of-the-art screenings, assessments, and treatments,youth with anxiety disorders often remain undetected anduntreated [3, 4]. Youth with untreated anxiety can experiencelower achievement scores [5], educational underachievementin young adulthood [6], or impairment in social and emotional

functioning [7]. Furthermore, children and adolescents withan anxiety disorder have been found to be more at risk ofdeveloping comorbid anxiety disorders [8, 9] and othercomorbid psychiatric conditions such as depression [10], be-havior disorders [11], or substance use disorders [12].

The development of anxiety can be understood through atriple-vulnerability framework [13]. This framework sug-gests that the development of anxiety in youth is associatedwith the interaction among a biological predisposition, apsychological vulnerability that limits a sense of control,and learned experiences that focus on anxiety. Examples ofa biological predisposition include a family history of anx-iety disorders or an anxious/shy temperament that may beassociated with more socially withdrawal behaviors [14]. Alimited sense of control is characterized by parental accep-tance/rejection [15, 16] and/or parental overprotection orover-controlling parents [17], impacting the ability of youthto cope effectively with anxiety. Learned experiences in-clude continual focus on anxiety-producing events that areviewed as dangerous or threatening [13], resulting in mal-adaptive responses to stress. Thus, in large part, children andadolescents with anxiety disorders experience significantdeficits in coping when faced with stressful events. There-fore, the main goal of treatment of anxiety disorders focusesits efforts on helping youth develop adaptive coping strate-gies to deal effectively with their anxiety [18], as well asfamily interventions that target parents’ role and response toanxiety in their child [19].

In this review, we describe factors that are essential toaddress in treatment of childhood anxiety. We begin bydescribing youth coping deficits and parenting behaviors,which illustrate how anxiety is maintained in anxious youth,followed by a description of the interventions that have beenshown to be effective in treating anxiety in youth, with aparticular emphasis on cognitive-behavioral therapy (CBT).CBT components that are used in the treatment of anxiety

D. Simpson (*) : L. Suarez : S. ConnollyDepartment of Psychiatry, University of Illinois at Chicago,Institute for Juvenile Research,1747 West Roosevelt Road,Chicago, IL 60608, USAe-mail: [email protected]

L. Suareze-mail: [email protected]

S. Connollye-mail: [email protected]

Curr Psychiatry Rep (2012) 14:87–95DOI 10.1007/s11920-012-0254-2

disorders in youth and an integration of these CBT compo-nents to address deficits in coping and parenting behaviorsare described. Finally, we describe the life course anxietycan take if not treated, along with recommendations onfuture directions for treatment and research in this area.

Coping Deficits

Coping deficits are maladaptive strategies that are used byyouth to deal with anxiety or fear. They are linked tosustained levels of anxiety, are associated with a chroniccourse of anxiety [20], and are behavioral and cognitive innature. The use of these maladaptive strategies is negativelyreinforced because they are often associated with a reductionin anxiety or distress in the short term; however, they are notadequate for overcoming anxiety long term. Continued use ofthese strategies does not allow the individual to disconfirm hisor her fear and interferes with learning appropriate strategiesfor dealing with anxiety or fear.

Anxious youth tend to use more maladaptive coping strat-egies than adaptive strategies in response to negative lifeevents than nonanxious youth [20]. Specifically, these authorsfound that anxious youth focused more on negative aspects ofparticular situations and less on creating a rational response tohandle these negative events. Use of more maladaptive strat-egies has been associated with higher levels of anxiety [20]and amplification in fear [21]. Additionally, regardless of thetype of anxiety disorder, no differences in the use of maladap-tive coping strategies have been found among youth with onlyone anxiety disorder, although anxious youth with comorbiddepression have been found to use more maladaptive copingstrategies than youth with just anxiety [20], specifically con-sidering that anxiety and depression often overlap [22].

Maladaptive coping strategies commonly used by anxiousyouth include avoidance, distraction, rumination, self-blame,and catastrophizing [21, 23, 24]. The use of these maladaptivecoping strategies leads to threat overestimation, prevents theindividual from obtaining information that disconfirms a falsethreat, and often leads the individual to continue to avoid ordistract away from the anxiety [21]. Continued use of mal-adaptive coping strategies (eg, avoidance) is significantlyassociated with anxiety [24], a relationship not realized byanxious youth [21]. The extant literature indicates that usingmore safety-seeking behaviors (eg, holding on to an object toincrease the sense of safety during therapist-guided attemptsto gradually face feared situations, referred to as exposuretasks) is associated with a reduced response to treatment[25]. Engaging in these behaviors during exposure tasks isconsidered a form of avoidance, as they prevent the patientfrom learning that he or she can face that particular situationand therefore mastering the fear. Similarly, using distraction asa coping strategy in feared situations can be considered a form

of avoidance, particularly during the portion of treatment inwhich patients are asked to gradually face feared situations.The use of distraction coping should not always be viewed asa maladaptive coping strategy, as it may be helpful in the shortterm during certain non–life-threatening situations (eg, trips tothe dentist or blood draws), during which use of the strategymay allow the individual to engage in these behaviors, andcould be added as an early step in gaining mastery of the fear.It is important to remember, though, that its use in thesesituations should be coupled with diaphragmatic breathing,guided imagery, and the like to help the child gradually andsuccessfully face these feared, non–life-threatening situations.An overreliance on distraction strategies may be detrimentalin the long run, such as using distraction to cope with stressorsthat are beyond one’s control (ie, distracting one’s self whenfaced with knowing someone with an illness), and is related topoorer outcomes [26].

Another factor that impacts the way youth cope with anx-iety is the degree to which these youth believe they can controlthe stressor. For example, when the stressor is controllable,youth who use adaptive strategies (eg, positive reappraisal oractive coping strategies) to handle the stressor often report lessdistress [20]. However, perceived control over external stress-ful events and anxiety sensations predicts higher levels ofanxiety [27]. For example, when youth with obsessive-compulsive disorder (OCD) blamed themselves for mattersoutside their control, their use of negative coping behaviorsincreased [24]. Characteristics commonly observed amongyouth with OCD are related to more internalizing symptomsand functional impairment, suggesting that these youth oftenpresent to treatment with various deficits in coping [24]. Forexample, the use of avoidance was strongly related to obses-sions and compulsions, the presence of internalizing symp-toms, and functional impairment in family and schooldomains [24]. Pervasive slowness was associated with func-tional impairment in school, family, and social domains, aswell as internalizing symptoms [24]. Furthermore, youth withOCD report more doubting, seek more reassurance, and takemore responsibility for negative outcomes than do youth withother forms of anxiety disorders.

In addition to relying on their own interpretation of threat-ening situations to cope, anxious youth also look toward theirparent’s response to ambiguous or threatening situations. Useof maladaptive strategies may be reinforced if their parents failto help them learn adequate coping strategies because parentsmodel anxious behaviors themselves and may display over-controlling parenting styles [28].

Parental Factors

In addition to biological contributions to increased vulnerabilityfor anxiety, both extant research and our clinical practice

88 Curr Psychiatry Rep (2012) 14:87–95

indicate that parental anxiety and parental anxious behaviorsplay a role in childhood anxiety andmaintaining coping deficitsin their children [29]. Youth of anxious mothers are found todisplay more fearful cognitive biases than children of non-anxious mothers [30]. Youth with maladaptive coping strate-gies are more likely to have parents who express threat anduncertainty with their own ability to cope with anxiety-producing situations [31] as well as have parents who modelanxious behaviors such as avoidance [17, 32]. For example,Burstein and Ginsburg [32] and Becker and Ginsburg [33]found that children who had more difficulty coping with taskshad mothers who made anxious verbalizations, engaged inmore anxious behaviors (eg, wringing hands, biting lips), andmodeled anxious cognitions (eg, communication of threat).Furthermore, anxious parents tend to interpret ambiguous sit-uations involving themselves and their child as more threaten-ing than nonanxious parents, whereby youth of anxious parentsthen begin to avoid ambiguous situations based upon theirparents’ anxious cues [34].

Over-controlling parenting behaviors, while originallyintended to protect the child from harm, often result inreducing the child’s sense of autonomy. These behaviorsare associated with youth perceiving that they have lesscontrol over stressors; thus, they exhibit more anxiety [35].Specifically, a child’s report of external locus of control(belief that one does not have control over the environmentand one’s emotions) mediated the relationship between ma-ternal and child anxiety [35]. Furthermore, compared withmothers who provided more autonomy, mothers whogranted less autonomy had children who experienced moreanxiety when these youth held a negative belief about theirability to control anxiety symptoms and outcomes to stres-sors [35]. Mothers with higher anxiety more subtlyexpressed their worry about their child’s task performance,including having lower expectations for their child’s perfor-mance, and were associated with reports of more distressand poorer performance on tasks compared with motherswho were more supportive [33].

Other research suggests that parents who catastrophizetheir own abdominal pain have children who do the samewhen they have a stomachache, and these behaviors wererelated to the parents overcompensating for their child byrelieving their child of responsibilities [36]. This has signif-icant implications in child anxiety, as stomachache andnausea are common somatic complaints among these youth.If parents allow their children to stay home from schoolwhen their stomachaches are related to anxiety, avoidancereinforces their fear. Accommodation (eg, keeping a childhome from school, parents performing tasks for their childor providing reassurance) has been linked to poorer out-comes in youth and can interfere with the child learningadaptive coping strategies to deal with anxiety [37]. Addi-tionally, social anxiety in youth is associated with parents

who had fears of negative evaluation of their child [38].These authors identify that lack of parental encouragement,parents emphasizing the opinion of others, and parentalsociability are related to social anxiety in youth. This in turncreates an environment in which youth sense anxiety in theirparents and respond to stressful situations with avoidance orother maladaptive coping strategies.

Youth with parents who encourage them to view prob-lems catastrophically are over-controlling, promote less au-tonomy, model avoidance, develop maladaptive copingstrategies for dealing with anxiety, and do not obtain mas-tery over their environments or anxiety [33, 39]. Interest-ingly, Burstein and colleagues [29] proposed that increasedparental anxiety is associated with “increased parental con-scientiousness and concern.” They suggest that it is thisconnection between parental anxiety and concern thatbegins the process of over-controlling and less autonomy-granting behaviors. Parental involvement in treatmentshould therefore assist parents in learning how to makemeaning out of ambiguous situations to help their child copewith threatening situations [34].

Interventions for Anxious Youth

The decision to use psychosocial and psychopharmacologictreatments for anxious youth alone or in combination shouldbe based on the level of severity and impairment [40]. Psycho-social treatment alone is recommended for youth with mildseverity and minimal impairment, while combination treatmentwith medication and psychotherapy is recommended for youthwith more acute needs [41]. Selective serotonin reuptake inhib-itors have shown efficacy for childhood anxiety disorders incontrolled studies [40, 42]. Alternative psychotherapies andmedications for youth with anxiety disorders are reviewedelsewhere [4, 40, 43•, 44–46]. The psychotherapy treatmentthat has garnered the most empiric support in the treatment ofchildren and adolescents with anxiety and therefore is coveredmore thoroughly in this paper is CBT [18, 40, 47, 48•]. CBT forchild anxiety addresses cognitive distortions that exaggerate thelevel of threat posed by situations, avoidance behaviors, seek-ing reassurance, and preforming rituals—all maladaptive cop-ing strategies for dealing with anxiety. CBT attempts tofamiliarize anxious youth with the links among anxious cogni-tions, feelings, and behaviors that perpetuate an anxious re-sponse to assist them in learning alternative coping responseswhen faced with anxiety-producing stimuli.

Cognitive-Behavioral Therapy Outcomes

Evidence for the usefulness of CBT has been well-documented [49]. Hedtke et al. [25] found that the use of

Curr Psychiatry Rep (2012) 14:87–95 89

more appropriate coping strategies was associated with fewerinternalizing symptoms. Lewin and colleagues [24] also indi-cated that CBT for OCD (exposure and response prevention)was associated with significant reductions in the use of avoid-ance, doubting, and over-responsibility.

Recent evidence supports both individual and familyCBT as more effective in treating youth with anxiety dis-orders than usual care [50], and in fact, when both parentshad anxiety disorders, the family modality outperformedindividual treatment. In another recent study, no differenceswere found between individual and group therapies [51].Another recent study revealed that group CBT for anxietywas superior to a group support and attention condition [52].Thus, it is clear that individual, family, and group CBT areeffective in treating youth with anxiety disorders.

Components of Cognitive-Behavioral Therapy

The components of CBT for youth with anxiety includepsychoeducation, increasing coping strategies (somaticmanagement skills training, cognitive restructuring, andproblem solving), exposures, contingency management,and parental involvement [18, 47]. Table 1 describes diag-nostic characteristics for the various childhood anxiety dis-orders and details how certain CBT components are appliedto each disorder.

Psychoeducation

Psychosocial treatment should begin with offering psycho-education to the child and family regarding anxiety andwhat to expect throughout the treatment process. Thisshould include 1) an understanding of the adaptive functionof anxiety; 2) the connection among anxious thoughts,physical sensations signaling fear and worry, and avoidantbehaviors, as well as how each of these will be addressed intreatment by learning somatic management, cognitiverestructuring, problem solving, and exposure; and 3) learn-ing to identify problematic patterns of fear and anxiety thatinterfere with function. When discussing the interactionbetween the physiologic and behavioral responses, it isimportant to describe this as an automatic physiologic re-sponse to false threats that are associated with cognitivedistortions signaling that the event is threatening, whichthen leads to avoidance of the situation. Furthermore, neg-ative appraisals may lead to a physiologic or behavioralresponse that includes autonomic hyperarousal, avoidance,and/or reassurance-seeking behaviors [28]. The consequen-ces of these misappraisals and the behavioral responsesoften lead to continued anxiety and are considered ineffec-tive ways to cope with anxiety, as these behaviors do notallow the child to experience physiologic habituation (the

natural reduction of anxiety over time). Psychoeducation ismeant to continue throughout treatment to address issuesassociated with shifting from cognitive skill building to thebehavioral/exposure components, or to help re-engageyouth who are struggling with continued motivation.

Coping Strategies

Somatic Management

Youth are first taught to recognize shifts in their emotionaland physiologic states. Physiologic responses (eg, increasedheart rate, dizziness, stomach distress) are a common featurein response to feared situations [47]. The clinician canexplore the somatic reactions the youth has when anxious.Once the youth identifies that these physiologic symptomsare associated with anxiety, he or she can begin to useadaptive coping strategies to help himself or herself handlethe anxiety more appropriately. These strategies includediaphragmatic (belly) breathing, guided imagery, and pro-gressive muscle relaxation. Diaphragmatic breathing is char-acterized by slow, controlled, deep breaths that extend intoone’s diaphragm, allowing the child to take fuller breaths.Guided imagery is used to help the child imagine a situationin which he or she would feel relaxed and can imagine thisplace when experiencing heightened anxiety. The childdescribes a relaxing place to which he or she has been orone that he or she could imagine would be relaxing. In doingso, the child integrates the five senses into the guidedimagery to experience the situation as real as possible.

Progressive muscle relaxation consists of a systematicplan to tense and relax the muscles in the body. The goalis for the child to understand the difference between themuscles feeling tense and relaxed so when his or her bodytenses during anxiety-producing situations, the child realizesthat he or she has control in reducing the tension. Thepatient or clinician can make an audio recording of thesethree somatic management strategies, with the instructionthat the patient first practice relaxation exercises at timeswhen he or she is not feeling anxious. Once the child obtainsmastery using the strategy during times of low anxiety andstress, he or she will be better prepared in applying the skillswhen experiencing anxiety in the future.

These somatic management techniques should be prac-ticed regularly to help the child learn adaptive ways to copewith the anxiety. Once he or she has mastered these tasks,the child can begin to use them when recognizing physio-logic changes or as preventive steps prior to anxiety-producing situations. In our clinical experience, it is just asimportant for the parent (anxious or not) to learn thesestrategies. It helps the parent guide their child in practicingthem as well as helping the parent model the use of adaptivecoping strategies when anxious.


Table 1 Diagnostic characteris-tics and treatment of anxietydisorders in children

CBT cognitive-behavioral thera-py; GAD generalized anxietydisorder; OCD obsessive-compulsive disorder; SAD sepa-ration anxiety disorder

(Adapted from Connolly et al.[4])

Anxietydisorder

Diagnosticcharacteristics

CBTconsiderations

SAD Developmentally inappropriate fear anddistress with separation from home orsignificant attachment figures; excessiveworry about the child’s own or his orher parent’s safety and health whenseparated; difficulty sleeping alone

Cognitive restructuring of anxious thoughtswhen away from caregivers

Parents and school work together to addressschool refusal

Behavioral strategies to shape and extinguishtantrums, irritability, physical resistance

Parent training to increase child’sindependent functioning

GAD Chronic, excessive worry, lasting >6 mo inareas such as schoolwork, socialinteractions, family, health/safety, worldevents, and natural disasters, with at least1 somatic symptom, difficulty controllingworries, often perfectionistic, reassuranceseeking

Relaxation techniques to target physicalsymptoms of anxiety

Cognitive restructuring to challengepersistent and general worries

Problem-solving techniques are practiced toprepare for worry in real life situations

OCD Persistent thoughts, images, or impulses thatare disturbing, intrusive, and inappropriate,causing significant distress or anxiety(obsessions), followed by repetitivebehaviors that are meant to neutralize theemotional response to the obsessions(compulsions) that interfere with dailyfunctioning

Create a hierarchy

Involve parents to minimize accommodationof symptoms (eg, reduce amount ofreassurance provided by parents, reduceperforming rituals for the child)

Exposure to fears; can be in vivo or imaginalexposures

Prevent youth from performing rituals duringexposures

Social phobia Feel scared or uncomfortable in social orperformance settings; discomfort associatedwith social scrutiny and fear of beingembarrassed in social settings

Social skills training and practicing in groupsetting

Live exposure sessions in social situations

Increased social opportunities

Peer generalization component withnonanxious peers

Panic disorder Recurrent episodes of intense fear that occurunexpectedly; uncued, episodic panicattacks that include 4–13 somatic orcognitive symptoms; youth fear recurrentpanic attacks and their consequences; maydevelop avoidance of particular settings(agoraphobia)

Psychoeducation about physiologicprocesses that result in physical symptoms

Progressive muscle relaxation, breathingretraining, cue-controlled relaxation

Cognitive coping

Gradual exposure to agoraphobic situations

Interoceptive exposures (exposure to somaticsymptoms)

Selectivemutism

Persistent failure to speak, read aloud, or singin specific situations (eg, school) despitespeaking in other settings (eg, with family);children may whisper or communicatenormally with selected individuals in somesituations

Behavioral interventions in multimodalapproach

Positive reinforcement of nonverbal andverbal communication

Anxiety reduction

Behavioral program to shape appropriatecommunication in home, school,community settings

Address comorbid communication deficit,developmental delays, or second-languageacquisition as needed

Specific phobia Intense and persistent fear cued by thepresence of the feared object that almostalways invokes anxious response

Introduction to muscle relaxation

Development of fear-producing stimulushierarchy

Systematic graduated paring of items onhierarchy with relaxation


Cognitive Restructuring

One of the most important components of CBT is cognitiverestructuring. Instead of focusing on the fear of possiblenegative outcomes, anxious youth are encouraged to findalternatives to their feared thoughts or consequences bychallenging the validity of their negative cognitions. Aparticularly helpful strategy when the client is younger isto use cartoon “thought bubbles” to help the child identifynegative cognitions [53], and to list rational responses in aseparate thought bubble of the same cartoon. The therapistworks with the anxious youth to challenge the negativecognitions by asking a series of questions, including thefollowing:

& Are there other explanations for this?& Is that the worst that could happen?& If the worst thing did happen, could you deal with it?& Does the fear/emotion have to lead to or equal a negative

consequence?

The goal of asking these questions is to assist the child inlooking for alternative thoughts regarding his or her fears.Clinicians can encourage these youth to be “thought detec-tives” who are looking to challenge their negative thoughts.For example, a child who worries about getting a bad gradeon an examination is encouraged to find evidence that sup-ports this fear. The child may ask himself or herself howlong he or she studied and whether he or she understood thematerial when it was taught in class, and then determine ifthe answers support these fears. With repeated attempts atfinding alternatives to their anxious thoughts, this type ofadaptive coping strategy assists youth in realizing their fearsabout poor performance are likely exaggerated. Parents canhelp their child explore alternative coping thoughts and toconvey a message that they believe their child will besuccessful in performing to his or her full potential. Youthare also asked to evaluate, based on past experience, thelikelihood that their worst-case scenario will occur. Thus,the child finds evidence to refute the fears, and this evidenceallows the child to deal more effectively with anxiety.

It must be mentioned that some fears are not appropriatefor this type of intervention. For example, if a child fears hisor her parent’s death, the clinician would not ask, “If this didhappen, could you deal with it?” Instead, the clinicianshould recognize that this is a scary thought and that whenthe youth describes this type of fear, the therapist can en-courage the child to use somatic management strategies toreduce the level of anxiety, as well as problem-solving skillsdescribed next. Additionally, it is important for clinicians todiscuss with the youth and family possible connectionsbetween these worries and actual challenges to parentalhealth and identify the most appropriate coping strategybased on the family circumstances.

Problem Solving

Problem-solving coping strategies allow anxious youth toassess all possible outcomes to a problem associated withincreased anxiety, such as needing a teacher’s support for aproblem but being too afraid to ask for help. They can askthemselves “What are all of my possible options?” Exam-ples include, “I could get my mom involved” or “I couldwrite the teacher a note asking for help.” Then the child isasked to evaluate the best option and selects what is man-ageable for him or her at the time and will most likely solvethe problem. The therapist can role-play the possible optionswith the child in treatment. Ultimately, the child is encour-aged to select the best option first and continue trying otheroptions until he or she is able to solve the problemeffectively.

Exposure

Exposures are designed to help the child gradually facefeared situations. Exposures are meant to lead to habituationof physiologic reactions (ie, the natural reduction of anxiety)to the feared stimuli and to learning that the fear of theimagined consequence is often greater than what is actuallyexperienced, and ultimately to a reduction in avoidantbehaviors. In vivo exposures involve facing feared situa-tions live, while imaginal exposures involve facing fearedsituations orally or in writing. Exposures are successfulwhen the child experiences anxiety upon entering ananxiety-producing situation and remains in the situationlong enough for habituation to occur. As youth becomemore comfortable facing their fear, their overall anxiety isreduced, allowing them to continue exposures.

Before exposures commence, the clinician, along withthe child and parents, develop a fear hierarchy, a list of thechild’s fears organized from the lowest- to highest-rated fearsituations. This list will guide the implementation of expo-sure tasks throughout treatment. Each fear is given a SUDSscore (Subjective Units of Distress Scale [0–8], with highernumbers representing more intense fear). With the thera-pist’s guidance, the child will begin to face situations thatare rated low on the hierarchy and work up to more anxiety-producing situations. This systematic approach to exposureshelps the child to obtain first-hand knowledge that the fearwas not as predicted (a false threat) and that he or she wassuccessful in overcoming it. The clinician can also ask thechild several cognitive restructuring questions to determinewhether the feared consequences occurred. Additionally,prior to performing exposures, the clinician should reviewthe coping skills described above to help the child deal withanxiety during the exposures, as well as rewards. For thechild with OCD, exposures are accompanied by refrainingfrom performing a ritual, known as exposure and response


prevention [54]. Youth engage in exercises during whichthey are confronted with their fear either in vivo (eg, touch-ing dirty floors) or imaginal (eg, writing a story thatdescribes a house fire). After the exposure, the child isprevented from ritualizing (eg, washing hands or checkingthat a light is off).

Contingency Management

Contingency management is used in the treatment of allanxiety disorders to help the child or adolescent take riskswhen implementing the strategies listed above. This step isparticularly important because treatment of anxiety includesexperiencing higher levels of distress; thus, youth need to berewarded for this hard work. For example, the child oradolescent can earn rewards for practicing relaxation strate-gies, performing exposures, or using cognitive strategies.Parents should provide rewards for attempts at overcominganxiety (not just for completed exposures) until the child isable to fully benefit from cognitive restructuring and/orexposures. Use of rewards can encourage the child to con-tinue to use adaptive coping skills when experience anxiety.Rewards can include pencils, stickers, game time, or desig-nated time with a parent, or can be accumulated over timefor the child to earn a larger monetary reward. The ultimatereward occurs when the child recognizes that he or she isless anxious than prior to treatment.

Parental Involvement in Cognitive-Behavioral Therapy

Because parents can play a role in the development andmaintenance of anxiety disorders, their participation in treat-ment is very important. In particular, attention should begiven to the quality of parent–child interactions and com-munication, the role of parental anxiety in modeling anxiousbehavior, and increasing parental skill in supporting thechild’s use of coping skills learned in treatment [40]. Clini-cian’s discussions with parents should review the interactionbetween biological influences of anxiety, perceived control,parental and parenting factors, and learned experiences (ie,negative reinforcement) and anxiety in youth. Parental anx-iety and parenting factors such as over-control and modelingof anxiety are discussed as potentially contributing to in-creased anxiety in the child. Throughout treatment, parentswill benefit from corrective feedback to help them under-stand how certain behaviors initially intended to support thechild and minimize distress in the short term may actuallyreinforce and maintain anxious and avoidant behaviors inthe long term.

As an example, parents of youth with separation anxietydisorder or selective mutism should learn that if the parentkeeps the child close in social situations with strangers(separation anxiety disorder) or orders the child’s food at

restaurants all the time (selective mutism), the child will notbe motivated to face and engage in anxiety-provoking sit-uations and learn more appropriate coping strategies whendealing with anxiety. Clinicians can also help parents ofchildren with OCD recognize that completing rituals fortheir child to minimize distress in the short term only pro-longs their child’s anxiety in the long run.

Because parents of anxious children often see their childexperiencing significant distress and worry, it is natural forthem to want to remove their child from distressing situa-tions in order to limit distress [37]. However, with makingthese accommodations, parents inadvertently send the mes-sage that they do not believe the child is capable of solvingproblems or facing anxiety-provoking situations on his orher own. As treatment progresses, the therapist will askcaregivers to tolerate a certain degree of distress in orderto help the child learn that he or she is capable of gettingthrough the anxiety by using the new coping strategieslearned in therapy. Parent and child motivation for changeshould be addressed at all times in treatment, and motiva-tional interviewing strategies combined with CBT can bevery helpful [55].

Longitudinal Course of Anxiety into Adulthood

Anxiety disorders commonly emerge in childhood and ado-lescence [56]. Studies have found that an early diagnosis ofan anxiety disorder in childhood predicts continued andpersistent anxiety disorders as well as additional psychiatricconditions in adolescence [57] and young adulthood [58].Woodward and Fergusson [6] suggest that anxious youth areat risk of developing a plethora of psychiatric conditions asadults. Therefore, prevention efforts are necessary and effi-cacious in reducing long-term deficits in coping and func-tioning associated with anxiety [59]. Furthermore, researchregarding the long-term effects of exposure-based CBTsuggests that treatment effects extend into young adulthood[60].

Conclusions

CBTwith parental involvement can effectively address childcoping deficits and parental behaviors that support andmaintain anxiety [50, 61]. Despite the wealth of empiricdata supporting the effectiveness of CBT in treating childrenand adolescents with anxiety disorders, some youth whoreceive CBT do not improve [52, 62]. More research isneeded to determine the extent to which treatment outcomesmay be influenced by the presence of additional comorbiddiagnoses, increased family and community stressors, orlimited parental involvement in treatment. Additionally,


clinical trials applying standardized and manualized CBTmay lack the flexibility needed to tailor the coping skillstaught to the specific coping deficits that the child presentswith at the start of treatment, spending equal time on allskills rather than spending more time on the skills requiringmore assistance. For this reason, improved assessments ofspecific coping deficits for anxious youth are needed at thebeginning of treatment (Simpson, unpublished data). Amore complete understanding of all coping strategies usedby anxious youth will assist the clinician in determining thebest approach in minimizing the use of these maladaptivestrategies and replacing them with more adaptive ones.Additionally, greater attention to parental involvement intreatment emphasizing modeling and support of adaptivecoping and non-avoidance is warranted.

More research is needed to understand cultural factorsthat may be associated with patterns of support seeking andcoping in youth. For example, Simpson (unpublished data)found that minority youth who had an anxious parent weremore likely to seek out the support of others compared withnonminority youth. This speaks to the differential emphasisthat may be placed on use of social support between Cau-casian and non-Caucasian youth. Understanding ethnic dif-ferences will more fully assist in offering a tailored approachto treating anxiety in children and adolescents.

Disclosure No potential conflicts of interest relevant to this articlewere reported.

References

Papers of particular interest, published recently, have beenhighlighted as:• Of importance

1. Costello EJ, Egger HL, Angold A. Developmental epidemiologyof anxiety disorders. In: Ollendick TH, March JS, editors. Phobicand anxiety disorders in children and adolescents. New York:Oxford University Press; 2004. p. 334–80.

2. Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in aneglected population: prevalence of anxiety disorders in pre-adolescent children. Clin Psyc Rev. 2006;26:817–33.

3. Chavira DA, Stein MB, Bailey K, Stein MT. Child anxiety inprimary care: prevalent but untreated. Depress Anxiety.2004;20:155–64.

4. Connolly SD, Suarez L, Sylvester C. Assessment and treatment ofanxiety disorders in children and adolescents. Curr Psychiatry Rep.2011;13:99–110.

5. Ialongo N, Edelsohn G, Werthamer-Larson L, et al. The signifi-cance of self-reported anxious symptoms in first grade children:prediction to anxious symptoms and adaptive functioning in fifthgrade. J Child Psychol Psychiatry. 1995;36:427–37.

6. Woodward LJ, Fergusson DM. Life course outcomes of youngpeople with anxiety disorders in adolescence. J Am Acad ChildAdolesc Psychiatry. 2001;40:1086–93.

7. Beidel DC, Turner SM. Childhood anxiety disorders: a guide toresearch and treatment. Routledge: New York; 2005.

8. Bittner A, Egger HL, Erkanli A, et al. What do childhood anxietydisorders predict? J Child Psychol Psychiatry. 2007;48:1174–83.

9. Verduin TL, Kendall PC. Differential occurrence of comorbiditywithin childhood anxiety disorders. J Clin Child and AdolescPsychology. 2003;32:290–5.

10. Lewinsohn PM, Zinbarg R, Seeley JR, et al. Lifetime comorbidityamong anxiety disorders and between anxiety disorders and othermental disorders in adolescents. J Anxiety Disord. 1997;11:377–94.

11. Kendall PC, Brady EU, Verduin TL. Comorbidity in childhoodanxiety disorders and treatment outcome. J Am Acad Child AdolescPsychiatry. 2001;40:787–94.

12. Schuckit MA, Hesselbrock V. Alcohol dependency and anxietydisorders: what is the relationship? Am J Psychiatry.1994;151:1723–34.

13. Suarez LM, Bennett SM, Goldstein CR, Barlow DH. Understandinganxiety disorders from a “triple vulnerabilities” framework. In:Anthony M, Stein M, editors. Handbook of anxiety and the anxietydisorders. New York: Oxford University Press; 2008. p. 153–72.

14. Hane AA, Cheah C, Rubin KH, Fox NA. The role of maternalbehavior in the relation between shyness and social reticence inearly childhood and social withdrawal in middle childhood. SocDev. 2008;17:795–811.

15. Ginsburg GS, Schlossberg MC. Family based treatment of child-hood anxiety disorders. Int Rev Psychiatry. 2002;14:143–54.

16. Rapee RM. The development of generalized anxiety disorders. In:Vasey MW, Dadds MR, editors. The developmental psychopathologyof anxiety. Oxford: Oxford University Press; 2001. p. 481–503.

17. Wood JJ, McLeod BD, Sigman M, et al. Parenting and childhoodanxiety: theory empirical findings and future directions. J ChildPsych and Psychiatry. 2003;44:134–51.

18. Gosch EA, Flannery-Schroeder E,Mauro CF, Compton SN. Principlesof cognitive-behavioral therapy for anxiety disorders in children. J CogPsychother: An Int Q. 2006;20:247–62.

19. Maid R, Somokowski P, Bacallao M. Family treatment of childhoodanxiety. Child Family Social Work. 2008;13:433–42.

20. Legerstee JS, Garnefski N, Jellesma FC, et al. Cognitive coping inchild anxiety disorders. Eur Child Adolesc Psychiatry.2010;19:143–50.

21. Helbig-Lang S, Petermann F. Tolerate or eliminate? A systematicreview on the effects of safety behavior across anxiety disorders.Clin Psychol Sci Prac. 2010;17:218–33.

22. Gaylord-Harden NK, Elmore CA, Campbell CL, et al. An exam-ination of the tripartite model of depression and anxiety symptomsin African American youth: stressors and coping strategies ascommon and specific correlates. J Clin Child Adolesc Psychol.2011;40:360–74.

23. Legerstee JS, Garnefski N, Verhulst FC, et al. Cognitive coping inanxiety-disordered adolescents. J Adolesc. 2011;34:319–26.

24. Lewin AB, Caporino N, Murphy TK, et al. Understanding clinicaldimensions in pediatric obsessive compulsive disorder. Child Psy-chiatry Hum Dev. 2010;41:675–91.

25. Hedtke KA, Kendall PA, Tiwari S. Safety-seeking and copingbehavior during exposure tasks with anxious youth. J Clin ChildAdolesc Psychol. 2009;38:1–15.

26. Landis D, Gaylord-Harden NK, Malinowski SL, et al. Urbanadolescent stress and hopelessness. J Adolesc. 2007;30:1051–70.

27. Cannon MF, Weems CF. Cognitive biases in childhood anxietydisorders: do interpretive and judgment biases distinguish anxiousyouth from their non-anxious peers? J Anxiety Disord.2010;24:751–8.


28. Morren M, Murs P, Kindt M, et al. Emotional reasoning andparent-based reasoning in non-clinical children, and their prospec-tive relationships with anxiety symptoms. Child Psychiatry HumDev. 2008;39:351–67.

29. Burstein M, Ginsburg GS, Tein JY. Parental anxiety and childsymptomatology: an examination of additive and interactiveeffects of parent psychopathology. J Abnorm Child Psychol.2010;38:897–909.

30. Schneider S, Unnewehr S, Florin I, et al. Priming panic interpreta-tions in children of patients with panic disorder. J Anxiety Disord.2002;16:605–24.

31. Muris P, Field AP. The role of verbal threat information in thedevelopment of childhood fear. “Beware the jabberwock!”. ClinChild Fam Psychol Rev. 2010;13:129–50.

32. Burstein M, Ginsburg GS. The effect of parental modeling ofanxious behaviors and cognitions in school-aged children: Anexperimental pilot study. Behav Res Ther. 2010;506–515.

33. Becker KD, Ginsburg GS. Maternal anxiety, behaviors, andexpectations during a behavioral task: relation to children’s self-expectations. Child Psychiatry Hum Dev. 2011;42:320–33.

34. Lester KJ, Field AP, Oliver S, et al. Do anxious parents interpretivebiases towards threat extend into their child’s environment? BehavRes Ther. 2009;47:170–4.

35. Becker KD, Ginsburg GS, Domingues J, et al. Maternal controlbehavior and locus of control: examining mechanisms in the relationbetween maternal anxiety disorders and anxiety symptomatology inchildren. J Abnorm Child Psychol. 2010;38:533–43.

36. Langer SL, Romano JM, Levy RL, et al. Catastrophizing andparental response to child symptom complaints. Children’s HealthCare. 2009;38:169–84.

37. Storch EA, Larson MJ, Muroff J, et al. Predictors of functionalimpairment in pediatric obsessive-compulsive disorder. J AnxietyDisord. 2010;24:275–83.

38. Schreier S, Heinrichs N. Parental fear of negative child evaluationin child social anxiety. Behav Res Ther. 2010;48:1186–93.

39. Chorpita BF, Barlow DH. The development of anxiety: the role ofcontrol in the early environment. Psychol Bull. 1998;124:3–21.

40. American Academy of Child and Adolescent Psychiatry. Practiceparameter for the assessment and treatment of children and adoles-cents with anxiety disorders. J Am Acad Child Adolesc Psychiatry.2007;46:267–83.

41. March JS, Ollendick TH. Integrated psychosocial and pharmaco-logical treatment. In: Ollendick TH, March JS, editors. Phobic andanxiety disorders in children and adolescents. New York: OxfordUniversity Press; 2004. p. 141–72.

42. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioraltherapy, sertraline, or a combination in childhood anxiety. JAMA.2008;2753–2766.

43. • Connolly SD, Suarez LM. Generalized anxiety disorder, specificphobia, panic disorder, social phobia, and selective mutism, InDulcan’s Textbook of Child and Adolescent Psychiatry, Editedby Dulcan MK. Arlington, VA, American Psychiatric Publishing,Inc; 2010. p 299–323. This book chapter provides information onetiology, course, assessment, and treatment of various childhoodanxiety disorders.

44. In-Albon T, Schneider S. Psychotherapy of childhood anxietydisorders: a meta-analysis. Psychother Psychosom. 2007;76:15–24.

45. Seidel L, Walkup JT. Selective serotonin reuptake inhibitor use in thetreatment of pediatric non-obsessive-compulsive disorder anxietydisorders. J Child Adolesc Psychopharmacol. 2006;16:171–9.

46. Reinblatt SP, Riddle MA. The pharmacological management ofchildhood anxiety disorders: a review. Psychopharmacology.2007;191:67–86.

47. Albano AM, Kendall PC. Cognitive behavioural therapy for childrenand adolescents with anxiety disorders: clinical research advances.Int Rev Psychiatry. 2002;14:129–34.

48. • Rapee RM, Schniering CA, Hudson JL. Anxiety disorders duringchildhood and adolescence: origins and treatments. Annu Rev ClinPsychol. 2009;5:311–341. This article reviews the etiology, treat-ment using a developmental perspective, change mechanisms, andprevention of anxiety disorders in children and adolescents.

49. Cartwright-Hatton S, Roberts C, Chitsabesan P, et al. Systematicreview of the efficacy of cognitive behavior therapies for child-hood and adolescent anxiety disorders. Br J Clin Psychol.2004;43:421–36.

50. Kendall PC, Hudson JL, Gosch E, et al. Cognitive-behavioraltherapy for anxiety disordered youth: a randomized clinical trialevaluating child and family modalities. J Consult Clin Psychol.2008;76:282–97.

51. Liber JM, Van Widenfelt BM, Utens E, et al. No differencesbetween group versus individual treatment of childhood anxietydisorders in a randomised clinical trial. J Child Psychol Psychiatry.2008;49:886–93.

52. Hudson JL, Rapee RM, Deveney C, et al. Cognitive-behavioraltreatment versus an active control for children and adolescentswith anxiety disorders: a randomized trial. J Am Acad ChildAdolesc Psychiatry. 2009;48:533–44.

53. Kendall PC. Cognitive-behavioral therapy for anxious children:therapist manual. 2nd ed. Ardmore: Workbook Publishing; 2000.

54. March JS. MulleK: OCD in children and adolescents: a cognitive-behavioral treatment manual. New York: Guilford Press; 1998.

55. Simpson D. Adolescents with OCD: An integration of the trans-theoretical model with exposure and response prevention. BestPractices in Mental Health: An international J. 2009;14–28.

56. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbiditysurvey replication. Arch General Psychiatry. 2005;62:593–602.

57. Bittner A, Egger HL, Costello EJ, et al. What do childhood anxietydisorders predict? J Child Psychol Psychiatry. 2007;48:1174–83.

58. Copeland WE, Shanahan L, Costello JE, et al. Childhood andadolescent psychiatric disorders as predictors of young adult dis-orders. Arch Gen Psychiatry. 2009;66:764–72.

59. Ginsburg GS. The child anxiety prevention study: interventionmodel and primary outcomes. J Consult Clin Psychol.2009;77:580–7.

60. Saavedra LM, Silverman WK, Morgan-Lopez AA, et al. Cognitivebehavioral treatment for childhood anxiety disorders: long-termeffects on anxiety and secondary disorders in young adulthood. JChild Psychol Psychiatry. 2010;51:924–34.

61. Khanna MS, Kendall PC. Exploring the role of parent training inthe treatment of childhood anxiety. J Consult Clin Psychol.2009;77:981–6.

62. Compton SN, Burns BJ, Egger HL, et al. Review of the evidencebase for treatment of childhood psychopathology: internalizingdisorders. J Consult Clin Psychol. 2002;70:1240–66.


Documents

Treatment and Outcomes for Anxiety Disorders Among Children and Adolescents: A Review of Coping Strategies and Parental Behaviors