1. Part IV: Internalizing Behavior Disorders

2. Anxiety Disorders Chapter 16 Carl F. Weems and Wendy K. Silverman

3. HISTORICAL CONTEXT DSM-II (1968) Only one specific childhood anxiety category: overanxious reaction. The DSM-III (1980) New broad category termed anxiety disorders of childhood and adolescence. Separation anxiety disorder Overanxious disorder Avoidant disorder DSM-IV (1994) The same basic definitions of anxiety disorders apply to children, adolescents, and adults, with the exception of separation anxiety disorder which requires onset before age 18.

4. TERMINOLOGICAL AND CONCEPTUAL ISSUES Anxiety is a multicomplex response system, involving affective, behavioral, physiological, and cognitive components (Barlow, 2002; Lang, 1977). A core defining feature of anxiety is emotion dysregulation of the anxiety response system (Weems, 2008). Primary features of anxiety problems as anxious emotion and may be expressed behaviorally, cognitively, physiologically, or interpersonally. Secondary features of anxiety are aspects that differentiate specific categories of anxiety disorder (Weems, 2008). For example, worry about separation from parents is specific to separation anxiety disorder.

5. DIAGNOSTIC ISSUES AND DSM- IV CRITERIA DSM-IV (1994, 2000) Specific phobias Social anxiety disorder Generalized anxiety disorder Separation anxiety disorder Obsessive compulsive disorder Panic disorder Posttraumatic stress disorder (PTSD)

6. PREVALENCE Disorders being most prevalent in children ages 6 to 12: Any anxiety disorder (12.3%) Specific phobia (6.7%) Separation anxiety disorder (3.9%) Social phobia (2.2%) Generalized anxiety disorder (1.7%) Disorders being most prevalent in adolescents: Any anxiety disorder (11.0%) Specific phobia (6.6%) Social phobia (5.0%) Separation anxiety disorder (2.3%) Generalized anxiety disorder (1.9%) Panic disorder (1.1%)

7. RISK FACTORS AND ETIOLOGICAL FORMULATIONS Theoretical Framework Symptoms of anxiety and phobic disorders can be understood as stemming from transactions among biological vulnerabilities (e.g., genetic, neural) and environmental risk factors (e.g., parenting, exposure to trauma) that produce emotion dysregulation, distress, and impairment. Etiological influences: Genetics Temperament Physiology (biology) Operant, observational, and respondent learning (associative learning) Information processing and stimulus/event interpretation (cognition) Attachment relations and sociability (socialization) Interactions among these processes in diverse contexts (e.g., parent- child relationships, family, home, school, community)

8. RISK FACTORS AND ETIOLOGICAL FORMULATIONS Biological Processes Genetic influences Central nervous system Peripheral nervous system Associative Learning Processes Classical aversive conditioning Vicarious acquisition through observational learning or modeling Verbal transmission of information Escape conditioning or negative reinforcement

9. RISK FACTORS AND ETIOLOGICAL FORMULATIONS Cognitive Processes Encoding, interpretation, and recall Selective attention Memory biases Interpretation biases Judgment biases Social and Interpersonal Processes Secure attachment Overcontrolling parenting Social-interpersonal models

10. DEVELOPMENTAL PROGRESSION Age differences in the onset and expression of phobic and anxiety disorders: Separation anxiety symptoms and animal fears are the predominant expression of anxiety in children ages 6 to 9. Generalized anxiety symptoms and fears concerning danger and death in children ages 10 to 13. Social anxiety symptoms and social/performance related fears in adolescents around ages 14 to 17.

11. COMORBIDITY, SEX DIFFERENCES, and CULTURAL CONSIDERATIONS Comorbidity ADHD ranges from 0% to 21% CD and ODD from 3% to 13% Depression from 1% to 20% Culture-specific socialization practices and family variables may have an impact on emotion expression and anxiety. Girls and women experience higher levels of anxiety and related symptoms than boys and men (Silverman & Carter, 2006).

12. THEORETICAL SYNTHESIS AND FUTURE DIRECTIONS Primary features of problematic anxiety are: Dysregulation of the anxiety response system Negative affect and distress/impairment that result from physiological arousal Significant advances have been made in understanding the developmental psychopathology of childhood anxiety disorders: Research has identified biological, behavioral, cognitive, interpersonal, and contextual processes important to understanding the origins of childhood anxiety.