1. health and fitness
2. disorders
3. mental disorder
4. panic and anxiety

GENERALIZED ANXIETY DISORDER
IN CHILDREN AND ADOLSCENTS:
IMPLICATIONS FOR RESEARCH AND PRACTICE
Leah M. Reuschel
42 pages
April 2011
This review summarizes the existing literature related to foundations of behavior,
assessment and measurement, applications to therapy, cultural considerations, ethical and
professional issues, and research needs regarding the provision of mental health treatment for
generalized anxiety disorder in children and adolescents.
CLINICAL COMPETENCY PROJECT APPROVED:
Date
Alvin E. House, Chair
Date
Margaret M. Nauta, Member
GENERALIZED ANXIETY DISORDER
IN CHILDREN AND ADOLSCENTS:
IMPLICATIONS FOR RESEARCH AND PRACTICE
LEAH M. REUSCHEL
A Clinical Competency Project Submitted in Partial
Fulfillment of the Requirements
for the Degree of
MASTER OF SCIENCE
Department of Psychology
ILLINOIS STATE UNIVERSITY
2011
GENERALIZED ANXIETY DISORDER
IN CHILDREN AND ADOLSCENTS:
IMPLICATIONS FOR RESEARCH AND PRACTICE
Leah M. Reuschel
42 pages
May 2011
Generalized anxiety disorder (GAD) is a widespread, debilitating disorder in children and
adolescents. Excessive anxiety in childhood causes great individual distress and functional
impairment (Albano et al., 2003) and is a major risk factor for mental health disorders later in
life. These facts call attention to the importance of early intervention and a greater understanding
of GAD in children and adolescents. This review discusses foundations of behavior, methods of
assessment and measurement, applications to therapy and therapeutic considerations, cultural
considerations and relevance to special populations, relevant ethical and professional issues, and
research challenges and needs regarding childhood GAD.
CLINICAL COMPETENCY PROJECT APPROVED:
Date
Alvin E. House, Chair
Date
Margaret M. Nauta, Member
CONTENTS
Page
CHAPTER
I.
INTRODUCTION
Diagnosis
Previous diagnosis: OAD
Rape Culture and Rape Myths
II.
FOUNDATIONS OF BEHAVIOR
Symptoms of GAD
Cognitive Symptoms.
Physiological Symptoms.
Behavioral Symptoms.
Phenomenological Symptoms.
Etiology
Epidemiology
Development/Age of Onset
Comorbidity
III.
ASSESSMENT AND MEASUREMENT
Multifaceted Assessment
Methods of Assessment
Clinical Interview
Checklist Measures
Behavioral observation
IV.
APPLICATIONS TO THERAPY
Cognitive Behavior Therapy
CBT Interventions.
Relaxation Training
Exposure Treatment
Systematic desensitization
Flooding exposure
Cognitive Restructuring
Acceptance-Based Behavior Therapy
Review of CBT Treatment Outcome Literature
Individual CBT
Group CBT
Technology Applications in CBT
Family and Parent-based Treatment
Communications Family Therapy
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Contingency Management/Parent Training
Play Therapy
Pharmacological Treatment
V.
VI.
CULTURAL CONSIDERATIONS AND RELEVANCE TO SPECIAL
POPULATIONS
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RELEVANT ETHICAL AND PROFESSIONAL ISSUES
36
Confidentiality
The Need for Knowledge Versus Protection of Child Participants
The Stigma Created by Labeling Youth with Mental Health Disorders
Exposure
VII.
RESEARCH CHALLENGES AND NEEDS
Methodological Issues
VIII.
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30
32
CONCLUSION
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1
Generalized Anxiety Disorder in Children and Adolescents:
Implications for Research and Practice
Generalized anxiety disorder (GAD) is a prevalent, debilitating disorder in children and
adolescents. Excessive anxiety is the most common mental health problem experienced in youth
(Albano, Chorpita, & Barlow, 2003) and causes individual distress and functional impairment
throughout children’s lives (Albano et al., 2003). Furthermore, excessive childhood anxiety is a
major risk factor for mental health disorders later in life. These facts call attention to the
importance of early intervention and a greater understanding of GAD in children and
adolescents.
Diagnosis
Generalized anxiety disorder is an anxiety disorder distinguished by excessive worry
about several areas of one’s life. GAD is defined in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric
Association, 2000) by excessive, difficult-to-control anxiety and worry about a number of events
and activities that is accompanied by various physiological symptoms, i.e., muscle tension,
restlessness/feeling keyed up or on edge, difficulty concentrating/mind going blank, being easily
fatigued, irritability, and sleep disturbance. In children, the diagnosis only requires at least one
physiological complaint to be present as opposed to at least three symptoms in adults (4th ed.,
text rev.; DSM–IV–TR; American Psychiatric Association, 2000).
Previous diagnosis: Overanxious Disorder
In previous editions of the DSM (American Psychiatric Association, 1994), excessive
worry and anxiety in children was labeled Overanxious Disorder (OAD), a diagnosis present in
the “Disorders of Childhood” section of the DSM-III (American Psychiatric Association, 1980),
and DMS-III-R (American Psychiatric Association, 1987). The diagnostic category of OAD,
2
however, had several problems including limited reliability, lack of external validity,
overdiagnosis, inappropriateness of the criteria, lack of distinctiveness from other disorders of
childhood, and uncertain relationship to adult disorders (Werry, 1991). Now it is recognized that
child, adolescent, and adult manifestations of excessive worry and anxiety symptoms are
fundamentally equal (House, 2002a). Thus, due to the lack of distinctiveness between youth and
adults symptoms, the former diagnosis of OAD was subsumed under the revised diagnosis of
GAD in the DSM-IV (American Psychiatric Association, 1994). This revision, however, does
not generally reflect a developmental perspective, thus clinicians have to translate the diagnostic
criteria into conditions that appropriate for a child’s age, development, gender, and culture
(Moore, March, Albano, & Thienemann, 2010).
Foundations of Behavior
Children and adolescents of both genders commonly experience anxiety symptoms
(Bernstein & Borchardt, 1991). Although anxiety, at certain levels, serves adaptive functions,
intense anxiety and worry can be quite debilitating. Anxiety disorders are the most frequent
mental health problems that afflict children and adolescents (Albano, Chorpita, & Barlow, 2003).
Childhood anxiety disorders cause individual distress as well as a broad range of functional
impairment throughout a child’s life (Albano et al., 2003). Furthermore, excessive childhood
anxiety is a major risk factor for adult mental health disorders. Childhood anxiety disorders are
often followed by adult anxiety disorders (Kim-Cohen et al., 2003), depression (Kovacs,
Gatsonis, Paulauskas, & Richards, 1989), and substance abuse (Kushner, Sher, & Beitman,
1990), calling attention to the importance of early intervention. The onset of GAD may be
gradual or sudden and, unsurprisingly, symptoms are often exacerbated by stress (Rapoport &
Ismond, 1996).
3
Because anxiety disorders are prevalent in and distressing to children and adolescents, a
vast comprehension of anxiety in this population is needed. However, our understanding of
anxiety in youth continues to be limited. Because youths’ mental capacities and emotions are
constantly developing and shifting, it can be difficult to distinguish between fears and worries
that are normal for a child’s developmental stage and those that may be of concern and
necessitate special attention. “Children’s Fears and Anxieties” (2004) outlines some typical
fears and worries of youth at certain developmental levels. Newborns normally fear loud noises
and falling, while a fear of strangers usually begins around 6 months and continues through the
age of 2 years. It is typical for pre-school age children to be afraid of separation from their
parents, darkness, paranormal creatures (e.g., ghosts and monsters), big animals, and masks.
Normal worries in children who are older include unsuccessful results in school, family deaths,
and tragic occurrences in the news such as terrorist attacks, war, kidnappings, and natural
disasters. Adolescents commonly have anxieties about their personal future and future of the
world, as well as social and sexual events and performances.
According to trait models of personality such as the Five-Factor Model (e.g., McCrae &
John, 1992), Neuroticism, or the tendency to experience negative emotions such as anxiety, is a
basic personality dimension. Anxiety is a fundamental emotion that at certain levels serves
adaptive functions such as motivation, protection, and survival (Moore et al., 2010). Childhood
fears, worries, and anxieties must be considered in their developmental context and only become
a problem if they persevere and cause serious personal distress, hinder development or
education, or greatly interfere in familial or social relationships (“Children’s Fears and
Anxieties”, 2004). Nevertheless, even subthreshold levels of anxiety in children can result in
considerable impairment and may necessitate attention and treatment (Moore et al., 2010).
4
Some researchers argue that because anxiety and depression are similar in several aspects
they should be combined into a single construct termed Negative Affectivity. Negative Affect
can be described as a general feature of subjective distress and includes a wide range of negative
mood states, including anxiety, depression, disgust, and hostility (Watson, Clark, & Carey,
1988). In terms of empirical and conceptual overlap, anxiety is closely related to depression.
Several studies have shown strong correlations in several measurements of anxiety and
depression in diverse samples, including children (Blumberg & Izard, 1986; Wolfe et al., 1987).
However, a major difference between anxiety and depression is the feature of anhedonia, which
is present in depression and absent from anxiety (Watson et al., 1988). While the strong
connection leads some researchers to propose that anxiety and depression are variations of a
single disorder, most personnel in the field continue to consider that the basic distinction is
appropriate and valid (Watson et al., 1988).
Symptoms of GAD
Anxiety itself can be seen as a multifaceted construct that can be studied from four
different approaches—cognitive, physiological, behavioral, and phenomenological. These
aspects of anxiety are discrete categories; rather they overlap and interconnect.
Cognitive Symptoms.
Worry and the disturbance of mental processes (e.g., thinking, planning, abstract
reasoning, problem solving, and recall) encompass the cognitive features of anxiety (Kendal et
al., 2004). With GAD, there is an overall attitude of apprehension. Children and adolescents
with GAD are often described as self-conscious, perfectionistic “worriers” (Beidel & Turner,
2005; Eisen & Kearney, 1995). The uncontrollable worry element of GAD may focus on several
5
general life themes such as the future, past events, and competence in areas including school,
sports, and peer relationships (Albano et al., 2003).
Children with GAD are often perceived as “little adults” because in addition to the typical
worries of youth, many of their worries often revolve around “adult” themes such as family
finances, health and safety of loved ones, relationships, schedules, punctuality, and tragic
events,—topics that normally only concern an older population (Kendall, Pimentel, Rynn,
Angelosante, & Webb, 2004). In addition, these children often display perfectionistic
tendencies, such as scrupulously completing or repeatedly redoing small tasks (e.g., simple
homework assignments) until they feel these tasks are completed perfectly. Often, adults will
perceive these perfectionistic behaviors as evidence of a child’s maturity and thoroughness and
will inadvertently reinforce the child for these behaviors. While the worries and perfectionistic
tendencies may be adaptive for some children, these behaviors become a clinical concern when
they interfere with other aspects of development and adjustment (Kendall, et al., 2004).
Cognitive distortions, most often “what if…” statements about wide-ranging stimuli,
infuse these children’s thought processes on a fairly continuous basis. Additionally, these
children overestimate the possibility of harmful outcomes, exaggerate anticipated consequences
to a disastrous degree, and undervalue their own capacity to cope in adverse situations (Albano,
et al., 2003). Silverman, La Greca, and Wasserstein (1995) demonstrated that non-clinical
children worry about low occurrence events as well, but children with GAD may not be able
distinguish that such events have a low likelihood of actually happening.
It appears that it is not the content or number of worries, but rather the frequency,
intensity, and functional impairment of worry that distinguishes between high levels and low
levels of anxiety in children and adolescents (Beidel & Turner, 2005). In fact, a study performed
6
by Weems, Silverman, and La Greca (2000) demonstrated that non-clinical children reported just
as many worries as the clinical samples, signifying that intense worry may lead to a reaction of
uncontrollability over the worry process. The same study cited that children with GAD reported
an average of 5.74 worries, spanning an average of 4.82 areas. The most common themes of
worry in youth with GAD included school, health, disasters, personal harm, and the future. The
children’s most frequent worries were in the realms of friends, peers, school, health, and
performance, while their most intense worries were in the areas of war, personal safety,
tragedies, school, and family (which are comparable to the list of typical developmental fears
presented earlier). Consistently, Muris et al. (2002) described that the worries most often
reported by children are not the same worries they experience as most intense.
There are developmental differences in regard to youth worry. Younger children (aged 68 years) reported fewer worries about appearance, performance, and minor issues as compared to
an older group (aged 12-16 years). Moreover, gender differences are also present in the
frequency of worry. Girls generally score higher than boys on measures of anxiety and specific
measures of worry frequency (Vasey & Daleiden, 1994).
When the cognitive symptoms of GAD and specific phobias were compared, children
with GAD were found to score significantly higher in both the intensity and the total number of
worries present (Muris et al., 2002). However, few group differences in the frequency and
content of worry were discovered; although notably, children with specific phobias reported
more worries about family and the health of others, while those with GAD worried more about
scapegoating and the future.
Physiological Symptoms.
7
The physiological element of anxiety revolves around the biological effects anxiety has
on the body. Physical symptoms generally reflect elevated sympathetic autonomic nervous
system activity and include increased heart rate and blood pressure, increased muscle tension,
muscle tremor, alterations in salivation and perspiration, bodily temperature changes, and
modifications of stomach gastric and acidic actions (Beidel & Turner, 2005). These symptoms
are caused by the release of cortisol and epinephrine in the brain when a threat is detected (Wood
& McLeod, 2008). These physiological changes are thought to serve an adaptive function by
enhancing motor performance for fight or flight behaviors.
In one sample, Tracey, Chorpita, Douban, and Barlow (1997) found that youth with GAD
endorsed experiencing several physical symptoms, including restlessness (74% of the sample),
irritability (68%), difficulties concentrating (61%), sleep disturbance (58%) headaches (36%),
muscle tension (29%), and stomachaches (29%).
Behavioral Symptoms.
The behavioral part of anxiety involves avoidance or escape behaviors that are activated
when an individual is confronted with fear-inducing cues. The avoidant behavior is then
negatively reinforced with a reduction of fear and decline of arousal. Excessive anxiety is
commonly conceptualized as being an exaggerated, distressful, non-functional arousal response
that expanded from what was once an adaptive escape reaction from danger (Borkovec, Alcaine,
& Behar, 2004). In GAD, the anxiety and avoidance behavior generalizes to non-threatening
cues; as a result, numerous objects and events that were previously harmless become cues that
evoke anxiety. In essence, individuals with GAD are in a constant state of vigilance (Rapoport
& Ismond, 1996).
8
Due to the self-conscious, perfectionistic nature of youth with GAD, they ask for and
require repeated reassurance from others (Beidel & Turner, 2005; Eisen & Kearney, 1995).
Children and adolescents with GAD usually demonstrate a rather debilitating restriction of ageappropriate social functioning and activities (Eisen & Kearney, 1995).
Phenomenological Symptoms.
Lastly, the phenomenological aspect of anxiety involves one’s subjective experiences and
feelings of anxiety. Anxiety is a natural human emotion with which everyone is familiar. The
feelings include an uncontrollable sense of urgency, impending doom, nervousness and
apprehension. This anticipatory anxiety is usually present in these children, especially in
situations in which their performance may be evaluated (Rapoport & Ismond, 1996). House
(2002b) noted that children suffering from GAD often manifest with a great amount of personal
distress and appear miserable.
Etiology
There is relatively little known about the etiology of GAD in children because research
on this topic has been fairly sparse (Kendall, Pimentel, Rynn, Angelosante, Webb, 2004).
However, Albano et al. (2003) suggested that anxiety is a function of several features, including
genetics, temperament, psychosocial factors, and parenting/family interactions (Barlow, 2002).
Although research with adults has suggested a potential genetic contribution to GAD
(Brown, 1999), no studies of this kind have been conducted in children. However, the overall
findings indicate that genes significantly contribute to a general vulnerability for anxiety
(Barlow, 2002). Recent research indicates that in children this general vulnerability for GAD
may also be related to depression, i.e., a shared genetic risk factor (Albano et al., 2003).
9
Additionally, other research suggests that the general vulnerability of anxiety may be
related to the temperament of a child (Kagan, 1997). This research is consistent with trait view,
which considers clinical anxiety to be extreme versions of personality characteristics distributed
in the general population. Research in this area has focused upon the relation between anxiety
and broader personality variables, such as the “Big Five” personality traits. Clark and Watson
(1991) studied childhood anxiety in relation to the tripartite model of emotion and found that the
personality factors of Negative Affect and Physiological Hyperarousal were positively related to
anxiety in children.
Researchers have also paid some attention to the role of cognitive patterns in the
causation of anxiety disorders in children. In both adults and children, combinations of cognitive
factors such as negative self-talk, anticipation of threat, and self-questioning may add to the
development of detrimental anxiety symptoms and disorders such as GAD (Kendall, 1991).
However, further research is required to better understand the function of negative cognitive
factors in childhood anxiety. Furthermore, parenting behaviors and parent-child attachment
styles can contribute to the development and maintenance of anxiety in children (Maid et al.,
2008). Two of these specific parenting characteristics that impact childhood anxiety are
acceptance and modeling of anxious behaviors. Low warmth and little parental acceptance can
cause children to be more prone to experience anxiety (Wood, McLeod, Sigman, Hwang, & Chu,
2003). Parents who experience anxiety and lack effective coping strategies transmit similar
behaviors to children through modeling, also causing childhood anxiety (Maid et al., 2008).
Some data suggest a possibility of significant differences between child- and adult-onset
GAD (Hoehn-Saric, Hazlett, & McLeod, 1993), which raises several questions regarding the
etiology of the disorder. Although results are mixed (Brown, 1999), some researchers suggested
10
that the etiology of GAD may differ depending on the age of onset (Kendall et al., 2004). Brown
(1999) wondered if, perhaps, childhood-onset GAD is more genetic-based while adult-onset is
more related to environmental effects. However, further research regarding the etiology and
course of GAD is needed to further explore this hypothesis. Similarly, as Kendall et al. (2004)
suggested, further exploration and research of biological factors, cognitive patterns, parenting
styles, early stressors, and temperament is warranted regarding the etiology of childhood GAD.
Epidemiology
As stated previously, anxiety disorders are the most common mental health disturbances
in youth (Albano, Chorpita, & Barlow, 2003). In their literature review of the epidemiology of
anxiety disorders in children and adolescents, Costello, Egger, and Angold (2004) concluded that
at current or three month prevalence estimates, anxiety disorders in youth range from 2-4
percent. At six month to 12 month estimates, the rates escalate to 10-20 percent, while the
lifetime estimates are only slightly higher. Moreover, GAD was found to be the most common
of the anxiety disorders to affect children and adolescents.
It appears that the prevalence of GAD may be higher in environments that exceedingly
prize and value success and achievement (Rapoport & Ismond, 1996). Rapoport and Ismond
(1996) acknowledged that in upper socioeconomic levels where performance expectations are
high, the existence of GAD is common.
Development/Age of Onset
Costello, Egger, and Angold (2004) reported that in a sample of youth who developed an
anxiety disorder before the age of 16, the total mean age of onset for GAD was 5.8 years old
(standard deviation = 5.7 years), which was the youngest for all anxiety disorders and unipoloar
depressive disorder. Broken down by gender, males showed a younger average onset age of
11
GAD by over 2 years; the average age of onset in males was 4.6 years and in females was 6.8
years. Also of note, compared to all other anxiety disorders and unipolar depressive disorder,
GAD had the largest interquartile range around the mean ages of onset at 12 years. This suggests
that, unlike childhood Panic Disorder and Separation Anxiety Disorder that have relatively short
windows for onset with quite small interquartile ranges at 3 years and 4 years respectively, GAD
has a relatively long window for possible onset in childhood. The course of generalized anxiety
disorder tends to be chronic, and research shows a continuation of the disorder into adulthood
(Wagner, 2001).
Comorbidity
As with all anxiety disorders, comorbid mental health disorders are common with GAD.
More than one disorder is often diagnosed in an individual with severe anxiety. House (2002a)
argued that in respect to anxiety disorders, “comorbidity tends to be the rule rather than the
exception” (p. 66). Anxiety disorders are especially associated with the diagnoses of other
anxiety disorders (Last, Strauss, & Francis, 1987). In particular, GAD is strongly associated
with Separation Anxiety Disorder. Last, Strauss, and Francis (1987) discovered that of a clinicbased sample of children who were diagnosed with an anxiety disorder, one third met criteria for
both Overanxious Disorder (now subsumed under GAD) and Separation Anxiety Disorder.
In addition, depressive disorders are strongly associated with GAD (Last, Hersen,
Kazdin, Finkelstein, & Strauss, 1987). Children and adolescents who suffer from both anxiety
and depression have a significantly poorer long-term prognosis that youth with only anxiety
(Pine, Cohen, Gurley, Brook, & Ma, 1998). Other common comorbid diagnoses of GAD include
Attention-Deficit/Hyperactivity Disorder (ADHD) and Substance-Related Disorders (Rapoport
& Ismond, 1996). Therefore, the presence of GAD in children or adolescents should prompt
12
clinicians to carefully assess for the existence of other anxiety disorder, mood disorder, and
ADHD symptoms. Additionally, clinicians should make certain to evaluate for possible alcohol
and other drug use in adolescents who present with GAD or anxiety symptoms.
Assessment and Measurement
Anxiety disorders can be more difficult to diagnose and assess in children as compared to
adults because incomplete syndromes and symptoms of overlapping disorders may occur in
addition to ordinary childhood fears and worries (Rapoport & Ismond, 1996). Also, the
distinctions and subclassifications of anxiety diagnoses continue to be debated even in adults.
In youth, assessment is difficult because children typically do not seek treatment on their
own. Rather, parents must first recognize a problem and be willing to seek help for their child
before an assessment will occur. In addition, accurate assessment of problems in chief emotional
states, such as anxiety, is very difficult due to the necessity of creating suitable conditions that
allow for accurate accounts of information and the limited ability of most young people to
communicate about emotional states (House, 2002b). However, over the past decade,
researchers have worked on the much-needed development and enhancement of several
promising anxiety assessment instruments and guides for use with children and adolescents
(Silverman & Ollendick, 2005).
Multifaceted Assessment
Due to its multifaceted nature, anxiety can be measured and assessed in several ways. It
is important to assess physiological, behavioral, cognitive, and phenomenological aspects of
anxiety across multiple contexts.
Because we know anxiety causes physiological changes in the body, arousal may be
measured and used as an assessment method for anxiety. Although several physical tension
13
measures have been used in laboratory settings, this technique is complicated because there is
great individual variability in the physical response to anxiety (Kendal et al., 2004). Children
and adolescents with GAD usually engage in avoidance and escape behaviors; therefore, a
careful assessment of avoidant behavior, adaptive behavior, and social functioning should be
completed (Greco & Morris, 2004). Since GAD’s defining characteristic is the cognitive aspect
of excessive worry, an exploration of this facet is essential. Roemer and Medaglia (2001) noted
that the assessment of GAD logically often begins with an investigation of cognitive worry. The
subjective, phenomenological experience of anxiety can usually easily be measured and selfassessed in children and adolescents. Children can often learn to portray their subjective anxiety
levels by using devices such as “fear thermometers” and other developmentally appropriate,
analog reporting measures. Like adults, adolescents can be taught to use the Subjective Units of
Distress Scale (SUDS) or other simple self-report scales used to depict personal levels of
anxiety.
Methods of Assessment
Preferably, several methods of assessment should be used including interview,
questionnaire, and behavioral observation and data should be collected from several sources such
as parents, teachers, and peers (Greco & Morris, 2004).
Clinical Interview.
The interview is the most commonly used method to obtain clinical information about the
client. By engaging in conversation, asking questions, and probing for information, critical
information regarding the client, and the client’s emotional state and anxiety symptoms may be
ascertained.
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However, youths’ self-reports of emotional states during an interview may be limited
because as mentioned earlier, children and adolescents often have difficulties communicating
about their feelings. Children still may be learning how to successfully distinguish between
different emotions and internal states, whereas adolescents still may be developing the
appropriate language to express their feelings. Additionally, all youth may lack the drive to
share their private inner experiences with an adult interviewer or clinician.
During an assessment, the interviewer should be honest, direct, respectful, and humble in
order to actively encourage the child’s or adolescent’s self-disclosure (House, 2002b). In
addition, basic interpersonal skills (e.g., attention, acceptance, accurate empathy, unconditional
positive regard, directed introspection, and feedback) will promote communication and further
understanding. When talking with children about their fears and anxieties in order to assess or
gain further understanding, examiners should do so with great tact and sensitivity that allows
children to sustain their self-respect and sense of control. Normalizing the sense of anxiety and
sharing similar personal experiences or experiences of other children can be quite helpful in
promoting children’s willingness to reveal their own fears and anxieties.
During the interview, the examiner can usually gain valuable information through the
observation of the youth’s emotions (Kendal et al., 2004). Facial expressions, body language,
affect, gaze, and emotional responses such as crying can be a rich source of data but should
always be checked verbally with the child. When assessing for GAD, special attention should
paid to any overt physical symptoms of anxiety such as muscle tension, jumpiness, or
restlessness.
Checklist Measures.
15
Checklist measures provide an additional means for evaluating anxiety in children and
adolescents. Self-report measures for the assessment of anxiety are used widely in clinical and
research settings (March & Albano, 1996). Self-report measures allow access to a vital source of
information: a child’s internal experience. This important information is not readily observable
and only available through the child’s introspection. A limitation of self-report instruments is
that they have the attached complication of certain reading comprehension levels requirements.
In addition, the measures are fixed, and further, supplementary information outside the generic
inquiry is not gleaned. However, the fixed nature of the instruments is also advantageous for the
purpose of objective norms, accessibility for experimental studies of validity and reliability, and
the ease of use, saving both time and cost.
Early self-report checklist measures for childhood anxiety typically characterized adult
measures that had been altered for a younger population (March & Albano, 1996). These
measures include the State-Trait Anxiety Inventory for Children (STAI-C; Spielberger, 1973),
the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1981), and the
Revised Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983). Greco and Morris
(2004) noted that the current general consensus regarding these assessment instruments is that
while they provide valid and reliable measure of distress, they lack discriminate validity and
consequently confound anxiety with other common comorbid diagnoses. The push to create
better assessment instruments that more usefully match up with the DSM-IV diagnoses led to the
development of a new wave of childhood anxiety measures: the Multidimensional Anxiety Scale
for Children (MASC; March et al.), the Screen for Child Anxiety Related Emotional Disorders
(SCARED; Birmaher et al. 1997, 1999), and the Revised Spence Children’s Anxiety Scale
(RCADS; Chorpita et al., 2000) (Moore et al., 2010).
16
The MASC is a self report measure that was developed to assess for clinical levels of
anxiety in children and adolescents. Moore et al. (2010) declared the MASC to be “the gold
standard of anxiety self-report assessment” (p. 633), and the measure has the distinctive asset of
a harm avoidance scale and a validity index. The MASC has strong psychometric properties
(Grills-Taquechel, Ollendick, & Fisak, 2008) and was developed by inventorying common
worries in children and adolescents and then sampling the key symptoms to discover the most
important anxiety symptoms and symptoms clusters. Thus, Moore et al. (2010) claimed that the
MASC in effect characterizes the population factor structure of youth anxiety. The MASC is
comprised of four major factors: physical symptoms, harm avoidance, social anxiety, and
separation/panic anxiety. If the empirically derived factor structures are averaged across all four
factors, they to a large degree match the DSM-IV-TR (American Psychiatric Association, 2000)
diagnosis for GAD (Grills-Taquechel et al., 2008). In addition, single factors of the MASC also
match the diagnostic clusters of separation anxiety disorder, panic disorder, and social phobia
(Moore et al., 2010).
The SCARED is another instrument that has strong psychometric properties (Birmaher et
al. 1997, 1999). Similar to the MASC, the SCARED maps directly onto anxiety disorder
diagnoses in the DSM-IV-TR (American Psychiatric Association, 2000). Another strength of
this instrument is its sensitivity to treatment exposure (Muris, Mayer, Bartelds, Tierney, &
Bogie, 2001). Both the MASC and SCARED include parent-report versions of the instruments.
The parent-report versions allow for a more comprehensive examination of the child’s anxiety.
Finally, the RCADS has several similar strengths as the SCARED (Chorpita et al., 2000)
but has been examined and tested less in the research literature because it is newer than the other
assessment instruments. Further research is necessitated to determine the distinctive
17
contributions and relative strengths of each of these newer childhood anxiety assessment tools
(Greco & Morris, 2004).
Behavioral observation.
Behavioral observation data may be particularly revealing in the case of GAD but, alone,
are not totally sufficient for diagnosis. Behavioral assessment can include both structured and
unstructured observations (Kendall et al., 2004). Unstructured observations by a clinician can
take place during the assessment sessions by noting any behaviors indicative of anxiety in the
child. Parent and teacher reports of unstructured observations can also be gathered.
Structured observations are performed by trained raters and involve direct observation of
the child in a naturalistic environment (Kendall et al., 2004). However, this type of observation
is seldom carried out and assessment instruments of observed behavior are rarely used (Greco &
Morris, 2004). In addition, behavioral measures have yet to be normed and standardized.
Applications to Therapy
Cognitive Behavior Therapy
For GAD and other anxiety disorders, cognitive behavioral therapy (CBT) is the most
well-researched treatment and usually the treatment of choice due to the positive research
evidence. Individual (e.g., Kendall, 1994; Kendall et al., 1997; Kendall, Hudson, Gosch,
Flannery-Schroeder, Suveg, 2008), group (e.g., Barrett, 1998; Muris, Meesters, & van Melick,
2002; Cobham, 2003), and family-centered (e.g., Barrett, Dadds, & Rapee, 1996; Silverman et
al., 1999; Rapee, 2000; Shortt, Barrett, & Fox, 2001; Lumpkin, Silverman, Weems, Markham, &
Kurtines, 2002) CBT treatments have received strong empirical support for treating childhood
anxiety. In fact, individual CBT, group CBT, and group CBT with parents have all been deemed
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“probably efficacious” in the treatment of childhood anxiety disorders (Silverman, Pina,
Viswesvaran, 2008; Flannery-Schroeder, 2004).
CBT can be delivered in two modes: individual therapy and group therapy. Both forms
use equivalent CBT interventions, but skills are simultaneously delivered to multiple people in a
group format compared to one-on-one in an individual format. In addition, CBT can be childcentered (i.e., Child Cognitive Behavior Therapy) or involve the family/parents in the treatment
process (i.e., Family Cognitive Behavior Therapy). Because childhood anxiety symptoms may
be reinforced by features of parenting (Wood et al., 2003), parent-child attachment (Thompson,
2001), and maternal anxiety (Moore, Whaley, & Sigman, 2004), treatments involving the whole
family may be beneficial and should be considered (Maid, Smokowski, & Bacallao, 2008).
CBT Interventions.
CBT focuses on modifying maladaptive behaviors and thought patterns and is comprised
of several treatments and interventions. Several CBT techniques are commonly implemented in
the treatment of childhood GAD, including relaxation training, exposure, and cognitive
restructuring, which are discussed in detail below. It is important to keep in mind that when
working with children and adolescents, clinicians must find creative and engaging ways to
deliver skills to youth in order to prevent CBT from being dull and boring.
Relaxation Training.
The goal of relaxation training is to reduce general arousal. It also teaches children to
become aware of the feeling of tension in their bodies and provides skills to decrease it. Because
high level of general arousal and body tension are common features of GAD, relaxation training
is a frequently used to treat individuals with GAD, including children and adolescents. Deep
breathing, guided imagery, and progressive muscle relaxation (PMR) are three common
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relaxation techniques used with children. The most empirically supported and commonly used
method of relaxation is PMR (Eisen & Kearney, 1995). PMR involves the systematic tension
and release of several muscle groups throughout the body.
When using relaxation training with youth, developmental age of the child should be
considered (Beidel & Turner, 2005). Young children have much shorter attention spans than
older adolescents and adults. Therefore, relaxation directions and sessions as a whole should be
shorter in duration when working with children. Relaxation sessions for adults can be at least 30
minutes in length, which is likely too long for young children (Beidel & Turner, 2005). In
addition, children may have difficulty understanding the directions or not have the physical
knowledge needed to tense a specific muscle area. In order to make relaxation understandable,
engaging, and meaningful for kids, instructions should be provided using familiar visual images
and objects. For example, Koeppen (1974) wrote a script containing instructions to “squish your
toes down deep into a mud puddle” instead of simply directing kids to tense and relax their feet
muscles. Other examples in Koeppen’s (1974) script include pretending to squeeze juice out of
lemon to tighten hands and arms, stretch like a cat to tense arms and shoulders, and chew a big
piece of gum to work the muscles of the jaw. Kids were also given images of a turtle pulling its
head into its shell to focus on the neck and shoulder muscles and a fly on the nose to tense the
nose and face. Clinician demonstrations of the various components are also helpful (Friedberg,
McClure, Garcia, 2009).
To learn relaxation, like any other skill, requires practice (Beidel & Turner, 2005).
Therefore, one training or demonstration session is not sufficient for children and adolescents to
obtain relaxation skills. Clinicians should encourage youth to practice these skills often between
therapy sessions. Providing recordings of the training session, copies of scripts, and practice
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checklists/reminders to the client and client’s family are some suggested ways to help children
learn to relax and reduce arousal.
Exposure Treatment.
When treating a child or adolescent with GAD, exposure interventions should be
considered. Exposure therapy involves exposing an individual to aversive stimuli for the goal of
reducing the individual’s anxiety and/or avoidance of the stimuli. Exposure is one of the most
commonly used techniques for treatment individuals with anxiety disorders (Eisen & Kearney,
1995). However, to perform exposure, the precipitating stimuli of the anxious reaction must be
known. In GAD, clear stimuli may be difficult to discern due to the multiple number and often
indistinct-nature of the stimuli present in this disorder; yet, in many cases, certain intense stimuli
may be singled out and become an object of exposure.
Exposure that is carried out in real situations is called in vivo exposure. For example, a
child who worries about riding elevators may be directed to enter an elevator and ride it floor to
floor. Another type of exposure that is often used in youth with GAD is imaginal exposure,
which is conducted by imagining or visualizing aversive stimuli. This type of exposure can be
used for almost any stimuli including social situations, unlikely occurrences, and physical
sensations. For example, a child who worries about throwing up can be directed to imagine the
sensation in detail using all senses repeatedly, until the anxiety aroused decreases. A common
form of imaginal exposure involves writing a detailed story about anxiety-provoking stimuli.
Then subsequent exposures can straightforwardly take place with readings of the story.
Exposure procedures can either be carried out in gradual or sudden manners. Due to the
intensity of elicited anxiety reactions, gradual exposures are generally desirable for many people,
especially children (Eisen & Kearney, 1995). Children will likely be more willing to participate
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in a therapeutic exposure intervention if they are gradually introduced to their fears beginning
with stimuli that evoke low intensity arousal rather than starting with sudden exposure to their
most feared stimuli. Furthermore, the gradual approach often allows the clinician and child to
development greater therapeutic rapport and trust (Eisen & Kearney, 1995), and the child is able
to develop confidence in his or her ability to overcome high-intensity fears with successful
achievement over each low intensity stimuli.
Systematic desensitization.
Systematic desensitization, a type of gradual exposure based on classical conditioning
that involves pairing feared stimuli with relaxation, has been found to be successful in the
treatment of children and adolescents with generalized anxiety (Kane & Kendall, 1989). This
form of exposure is one of the most frequently employed methods of treating childhood anxiety
disorders (Silverman & Kearney, 1991).
Systematic desensitization usually involves three steps: Relaxation training, construction
of a fear/anxiety hierarchy, and pairing relaxation with exposure to hierarchy items. Children are
first taught how to relax, most commonly using PMR (see above), in order to cope with the
anxiety elicited during exposure. Next, a fear/anxiety hierarchy, which is a list of usually about
10 situations related to the aversive stimuli ranked in ascending order of anxiety-provoking
intensity, is created in collaboration with the child. The final step involves pairing each item of
the hierarchy (starting at the bottom, from least intense to most intense) with relaxation until the
anxiety response is extinguished. Exposures may be imaginal, in vivo, or both. During
exposures children rate their anxiety level using rating scales (e.g., SUDS or a 1-10 scale).
When a child’s anxiety rating during an exposure is adequately low it is discontinued and the
process continues with the next item on the list. If a child’s rating indicate the exposure is too
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difficult to handle, then a clinician should withdraw to the previous item or create a midway step
(Eisen & Kearney, 1995).
Flooding exposure.
Another main exposure technique for treating anxiety is flooding. Flooding is a type of
exposure treatment that initially exposes a child to the most aversive stimulus in attempt to
effectively extinguish the anxiety reaction. Usually, there are no preliminary steps to exposure
such as relaxation training and anxiety hierarchies as in systematic desensitization. The client is
exposed to the maximum arousing stimulus from the very beginning Eisen and Kearney (1995)
do not recommend using flooding to treat children with severe anxiety or children under the age
of 7 years. Flooding may be preferable in some instances in order to increase time and cost
efficiency of treatment; however, there is little empirical research surrounding the success of
flooding treatments on children with GAD (Eisen & Kearney, 1995).
Cognitive Restructuring.
Cognitive restructuring is another CBT method commonly-used to treat GAD. Using
cognitive restructuring children are taught to examine their worries and replace the negative
thoughts with positive statements. The first step of cognitive restructuring is to teach the youth to
monitor his or her thoughts to identify cognitive distortions and understand the effects the
distortions play on behavior. Then, the therapist teaches the child to replace dysfunctional
thoughts with more adaptive thought patterns. Lastly, in a stance of guided discovery the child is
encouraged to test their beliefs via exposure to reality in order to experimentally debunk faulty
thought patterns and reinforce developing adaptive beliefs (Eisen & Kearney, 1995).
Developmental variables should be considered before implementing cognitive
interventions with children. As noted by Spence (2000), young children frequently have
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difficulty with the cognitive component of CBT due to underdeveloped abstract thinking and
introspection abilities. Therapists should present cognitive interventions in concrete and relevant
manners to children such as using visual representations on an easel or chalkboard.
Acceptance-Based Behavior Therapy.
Recently, acceptance-based behavior therapy (ABBT) has been used to treat GAD in
adults (Roemer& Orsillo, 2007; Roemer, Orsillo, & Salters-Pedneault, 2008). In two studies,
Roemer and Orsillo (2007) and Roemer, Orsillo, and Salters-Pedneault (2008) focused on
targeting experiential avoidance by using approaches intended to increase awareness and planned
action in fundamental life areas. The authors focused on the premise that individuals with GAD
negatively appraise their feelings, thoughts, and bodily sensations and then use worry as a way to
avoid these internal experiences (Roemer et al., 2008). ABBT was used in these studies to
directly target these problematic reactions and connections. In both trials, ABBT for the
treatment of GAD in adults was found to be successful and promising, with significant
reductions of GAD symptoms (Roemer & Orsillo, 2007; Roemer et al., 2008).
Although, currently, ABBT has not been studied in children or adolescents with GAD,
this form of treatment may generalize to a younger population; however, further investigation is
needed. Similar types of acceptance and mindfulness-based interventions present in Dialectical
Behavior Therapy (DBT) have been shown to be efficacious in treating a range of problems in
children and adolescents (Callahan, 2008). Distress tolerance and self-soothing are DBT
distraction and coping skills that may be particularly useful for anxious youth.
Review of CBT Treatment Outcome Literature.
As noted previously, CBT is the most well-researched treatment for childhood anxiety
disorders; therefore, there are several empirical studies published exploring the efficacy of many
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CBT programs and interventions, of both individual and group mode, as well as both childfocused and family-oriented forms. CBT has been found to be efficacious in treating childhood
anxiety disorders (Kendall et al., 2004). Most childhood anxiety treatments are not aimed
specifically to treat individual anxiety disorders but, rather, are usually used to treat a
combination of disorders such as GAD, separation anxiety, and social phobia. Therefore, much
of the data concerning GAD are intertwined with the data of other anxiety disorders, which can
cloud the derived implications for GAD as an individual diagnosis.
Individual CBT.
Kendall (1994) compared a manualized CBT program to a wait-list control, in the first
randomized clinical trial examining the efficacy of CBT in the treatment of childhood anxiety
disorders, including OAD/GAD. Sixty-four percent of treated children were diagnosis-free of
primary anxiety disorders at post-treatment, and gains were found to be maintained a full year
following termination. Kendal et al. (1997) replicated these positive treatment outcomes and
efficacy of CBT in the treatment of childhood anxiety in a second clinical trial.
The CBT approach used in the above study is a 16-20 session manualized program for
children (Kendall, Kane, Howard, & Siqueland, 1990) that incorporates behavioral techniques,
such as relaxation, exposure, and role playing, with facets of cognitive processing. The
program’s overall goal is for children to learn to identify their symptoms of anxiety, which they
then use as prompts for utilization of anxiety management skills. The Coping Cat Workbook
(Kendall, 1992) parallels the treatment sessions and provides exercises to facilitate child
engagement and attainment of skills.
Barrett, Dadds, and Rapee (1996) conducted a similar promising trial of individual child
CBT but with the addition of a family management component. Anxiety-disorderd children were
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randomly assigned to one of three groups: CBT, CBT with family management (CBT+FAM), or
wait-list control. Compared to 30% in the control group, 60% of children in both treatment
groups were diagnosis-free at post-treatment. Furthermore, after one year, 70% of children in
the CBT group and 95% in the CBT+FAM remained free of their anxiety disorder diagnoses.
Another CBT program designed for treating anxiety is children is the Preventing Anxiety
and Depression in Youth (PANDY) program (Friedberg, Crosby, Friedberg, Rutter, & Knight,
1999). The program is designed to be engaging and appealing to children and uses playful
applications such as experiential games, illustrated thought records, and videotapes that teach
and model skills. Friedberg et al. (2003) discovered that the PANDY program resulted in
symptom reduction in a small group of anxious children.
Group CBT.
Group therapy interventions are important in part because they maximize treatment costand time-effectiveness—two features that are gaining importance in current therapy for both
clients and clinicians. Several studies have examined the efficacy of group cognitive-behavior
therapy (GCBT) treatments for childhood anxiety disorders. Results have been very positive and
promising.
Barrett (1998) performed the first major study examining the efficacy of GCBT in
treating childhood anxiety disorders. Results showed that in the treatment of childhood anxiety
disorders, CBT interventions can be delivered as effectively in a group format as in an individual
format. This initial study examined both types of GCBT in two treatment condition: child-only
and family-based. At post-treatment, 64.8% of children across both treatment conditions were
free of anxiety disorder diagnoses compared to 25.2% of children on the wait list. Furthermore,
at the 12-month follow up, 64.5% of children in the child-only group were diagnosis free as well
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as 84.8% of children in the family-based group. In respect to comparisons between the two
treatment conditions, children receiving family-based GCBT showed marginal benefits on
clinician ratings and self-report measures compared to the child-based GCBT.
Several others studies examined the efficacy of family-based GCBT in the treatment of
childhood anxiety. Silverman et al. (1999), Rapee (2000), Shortt, Barrett, and Fox (2001), and
Lumpkin et al. (2002) all found family-based GCBT to be highly efficacious in generating and
maintaining gains in the treatment of childhood anxiety disorders, similar to the results of Barrett
(1998).
Other studies have focused upon examining the efficacy of child-focused GCBT. Muris,
Meesters, and van Melick (2002) and Cobham (2003) both found child-focused GCBT to be
efficacious in reducing childhood anxiety. Furthermore, Cobham (2003) specifically aimed to
explore the theory that anxious children with non-anxious parents need only child-focused
GCBT treatments to produce reductions in anxiety rather than significant parental involvement.
The results support the implication that children with anxiety disorders who have non-anxious
parents only need child-focused GCBT to achieve significant treatment gains.
However, one major question that remains in the literature revolves around parent
involvement in GCBT for the treatment of anxiety. As Ben-Amitay, Rosental, and Toren (2010)
explain, some models assert that anxiety in children may be propagated by parental and family
dynamics. Therefore, involving parents in treatment may help discontinue those family
dynamics and contribute to a decrease in anxiety. Barrett (1998) demonstrated early on in the
literature that children receiving GCBT with family involvement showed marginally greater
treatment gains than children in a child-focused GCBT. Several of the studies following this
publication implemented a GCBT intervention with some sort of parent involvement. However,
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as mentioned above, it has also been proposed and supported in the small pilot study by Cobham
(2003) that anxious children with non-anxious parents do not need parental involvement in
GCBT treatments to make treatment gains and reductions in anxiety symptoms. This area,
including all types of questions surrounding parental involvement, evidently requires further
investigation and attention in the future research.
Technology Applications in CBT.
Due to the efficacy of CBT in the treatment of anxiety disorders, multiple creative
applications using technology have been developed for the assistance of training cognitive and
behavioral techniques such as interactive computer programs and mobile telephone applications.
Children and adolescents are great candidates for technological applications of GAD treatments.
One technology-employing program described in Newman (1999) and Newman, Consoli,
and Taylor (1999) utilizes palmtop computers and special software called, “The Stress Manager”
in conjunction with regular therapy sessions in the treatment of GAD. This software was
designed to be very user friendly and is comprised of several interactive curricula including selfmonitoring, imaginal exposure, cognitive restructuring, and relaxation training. The palmtop
computer application has many advantages including the fact that it is easily portable, issues
reminders for self monitoring and homework, can improve accuracy of data, reiterates important
concepts, and allows for practice and application of CBT techniques between sessions in natural
environments. In addition, the prompts and reminders issued by the computer may improve
adherence to treatment. In a preliminary study, Newman et al. (1999) demonstrated that the
computer program was effective in assisting the reduction GAD symptoms in adult participants.
Although this program was not designed for youth, it could likely be successfully applied to
adolescents. Some clients may be uncomfortable with the use of technology in their treatment;
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however, youth typically are very at ease with computers and technology and will likely find
this, and similar applications appealing.
Another technology-based application that may be particularly useful for treating GAD in
adolescents is the use of cell phones as an adjunct to CBT. Most cell phones can be programmed
to set alarms that can act as prompts for self-monitoring or homework. In addition, Boschen and
Casey (2008) suggested that text messaging technology can allow the exchange of information
between client and therapist when other forms of communication are not convenient or feasible.
For example, text messages can be sent to clients to act prompts or to therapists to report selfmonitoring data. Youth have widely adopted text messaging as a normal part of communication
and will likely feel at ease with and attracted to this form of interaction.
Furthermore, Boschen and Casey (2008) highlight photograph, audio, and video
applications present on cellular telephones that may be used to assist in several potential
therapeutic interventions for the treatment of GAD, especially exposure-based interventions.
Clients can easily use their cell phone to expose themselves to pictures, sounds, or videos of
feared stimuli during exposure homework exercises and even record themselves performing such
tasks for review with their therapist. Finally, many mobile phones offer features such as Java,
Bluetooth, and internet access that allow the translation of programs, transfer of data, and access
to an incredibly vast amount of online information, respectively. These features can supplement
and assist the therapeutic process.
Family and Parent-based Treatment
This section includes two types of treatments that are aimed at and involve the family
and/or parents of a child with GAD (excluding family-based CBT treatment as it was covered in
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the previous section). The two types of treatments are communications family therapy and
contingency management/parent training.
Communications Family Therapy.
Although there is very little empirical research concerning communications therapy in
treatment in childhood anxiety disorders, researchers have suggested that this form of family
therapy may be effective. Communications family therapy addresses dysfunctional interactions
and communication patterns within families that may be maintaining anxiety symptoms (Maid,
Smokowski, & Bacallao, 2008). When anxiety is not elicited by certain contexts and is more
diffuse (as is common in GAD), Nichols and Schwartz (2004) suggested that linear CBT
strategies may be less helpful while more experiential approaches (e.g., communications therapy)
may be more beneficial. This approach uses techniques such as role plays and sculpting to alter
dysfunctional family roles that exacerbate anxiety in children.
Contingency Management/Parent Training.
Parents are very significant and influential in a child’s life. Consequently, when
attempting to reduce worry in children, therapists often must work with the parents to change
parental behaviors in order to achieve therapeutic goals. Parental training techniques that
improve parental reinforcement and discipline methods can be used to proximally shape a child’s
behavior (Eisen & Kearney, 1995). Therapists can also work with parents to improve avoidance,
modeling of anxious behavior, support, and motivation.
Although contingency management is most often used in the treatment of behavior
disorders, the same techniques are also commonly used to reduce externalizing behaviors that
often go with anxiety disorders (Eisen & Kearney, 1995). In many cases, parents may
inadvertently reinforce anxious behaviors in their children (Morris, & Kratochiwill, 1983). For
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example, giving worried children ample sympathy and attention or relieving them of household
chores supplies positive or negative reinforcement for the dysfunctional worry. Contingency
management is used to shift reinforcement to more adaptable responses, such as realistic beliefs,
exposure, or relaxation. Multiple interventions are commonly used to meet these ends, including
differential reinforcement, shaping, enhancing parent attention, command training, token
economy, and time out (Morris, & Kratochiwill, 1983).
Contingency management is not used as frequently as child-focused interventions in the
treatment of GAD, but research has shown that this parent training technique can be constructive
in treating childhood anxiety (Eisen & Kearney, 1995). Most studies demonstrating the
usefulness of contingency management are in the treatment of childhood phobic disorders
(Silverman, et al., 1999), school and social anxiety (Kearney & Silverman, 1990), and nighttime
fears (McMenamy & Katz, 1989). Although little research has been devoted specifically to the
efficacy of parental contingency management in the treatment of childhood GAD, many of the
techniques are often applicable with this population. However, due to the lack of empirical
support, Eisen and Kearney (1995) caution against the use of contingency management as the
primary treatment in most childhood anxiety cases and instead advocate for its use in
combination with child-focused interventions as discussed above.
Play Therapy
Play therapy is commonly used in the treatment of childhood emotional disorders (Eisen
and Kearney, 1995). Play therapy can be conceptualized through several different theoretical
orientations including psychodynamic, behavioral, and humanistic. Schaefer (1993) outlined
several therapeutic factors of play therapy related to various orientations, including promoting
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communication, overcoming resistance, relationship enhancement, fantasy, role-play, positive
emotion, metaphoric teaching, and overcoming developmental fears.
Lyness (1993) summarized therapeutic factors of play therapy that may be especially
important in the treatment of fears and anxiety, including identification, repetition, projection,
and denial. Children can use identification to better cope with anxieties by taking on a different
perspective. For example, a child can take on the role of a protective super hero who watches
over the house at night. Role-playing, imaginal exposure, modeling, and other CBT techniques
can simply be incorporated into this play therapy strategy (Eisen and Kearney, 1995). Lyness
(1993) described that repetition of play activities can help children overcome anxiety. For
example, games like hide and seek can promote adaptation and reduce anxiety to environmental
cues. This type of recurring play activity that allows a child to habituate to anxiety-provoking
cues can be conceptualized as a form of exposure. Children can use projection to transmit their
own embarrassing anxieties on play objects such as dolls, puppets, or stuffed animals. This can
allow a child to assume the role of a confident protector of the play object rather than disclose
anxious realities. Finally, Lyness (1993) explained that children can use denial to alter
unpleasant characteristics of reality through play fantasies. Child’s coping skills can be
improved if fantasy acts are similar to actual feared situations and played out in a gradual
manner. This is play therapy techniques is comparable the CBT intervention of graduated
imaginal exposure (Eisen & Kearney, 1995).
Although play therapy may have a lot to offer in helping children overcome anxiety, play
therapies used in the treatment of childhood anxiety have not been thoroughly and scientifically
tested (Eisen & Kearney, 1995). Case studies focusing on reducing anxiety (e.g., GAD; Boston,
Lush, & Grainger, 1991) have been published, but there is a severe lack of empirically supported
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studies. Further research is required to establish the efficacy of play therapy in treating childhood
GAD and other anxiety disorders.
Pharmacological Treatment
Early pharmacological treatment of anxiety in children utilized the benzodiazepine drug,
alprazolam. Despite early indications of alprazolam’s benefits in the treatment of childhood
anxiety, subsequently discerned negative outcomes, dose complications, and severe side effects
have led researchers to suggest the use of benzodiazepines as solely a last alternative
(Kratochvil, Kutcher, Reiter, & March, 1999).
The pharmacological treatment of choice for childhood GAD and other anxiety disorders
are selective serotonin reuptake inhibitors (SSRIs) (Beidel & Turner, 2005). Safety data have
shown SSRIs to have minimal side effects and high tolerance levels (Kratochvil, et al., 1999).
Two studies completed within the past decade have focused on studying the efficacy of SSRIs in
the treatment of childhood GAD. Birmaher et al. (2003) demonstrated anxiety symptomreduction using fluoxetine in the treatment of 74 children with GAD and/or other anxiety
disorders compared to a matching placebo. Significantly, 67% of the GAD-diagnosed children
who were treated with fluoxetine were rated as being much or very much improved by the
clinicians as compared to 36% of the placebo group. However, for the children with GAD, the
symptom reduction found in the fluoxetine group did not convert into enhanced functioning
measured by the Children’s Global Assessment Scale compared to the placebo group. In a trial
ran by Rynn, Siqueland, and Rickels (2001) that included 22 children and adolescents with GAD
as participants, results showed that participants treated with sertraline had significantly lower
scores on ratings of severity and symptoms compared to those who received a placebo.
However, this study had limitations surrounding the validity of the initial GAD diagnosis.
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Overall, it appears that SSRIs may be effective in the treatment of childhood GAD, but further
investigations are needed.
Cultural Considerations and Relevance to Special Populations
While the anxiety literature has given some consideration to cultural influences in adults,
there is a deficit in cultural research on child and adolescent populations (Albano et al., 2003).
Specific cultural symptoms and syndromes have not been explored in youth. For instance,
isolated sleep paralysis, a phenomenon that is conceptualized as a type of nocturnal panic, has
been found to be more prevalent in African American adults than in European American adults
(Barlow & Durand, 1995). However, it has not yet been evaluated if this event also occurs in
African American children (Albano, et al., 2003).
The once common assumption that anxiety is experienced and expressed in similar ways
across cultural groups has been challenged. Cross cultural researchers have made note that
advances in emotion theory emphasize the role of culture in the expression and emotional
experience of anxiety (Kirmayer, 1997). Although cross-cultural research has discovered
analogous rates of the presence of anxiety disorders across the world (Horwath & Weissman,
1997), there does seem to be disparity in the experience, expression, and description of anxiety
symptoms across cultural groups (Friedman, 2001). For example, Neal, Lilly, and Zakis (1993)
compared fears of white children and African American children using scores on the Fear Survey
Schedule for Children-Revised (FSSC-R). Although most fears were similar between the two
groups, a notable difference was a lack of school and embarrassment-based fears in the African
American children. In addition, Dong, Yang, and Ollendick (1994) used the FSSC-R to
determine fears in Chinese children and adolescents and compare them to Western samples. The
Chinese children reported greater social evaluative fears, such as test taking, and unlike Western
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samples, older Chinese children (ages 11-13 years) reported more fears overall than younger
children (ages 7-10).
Despite the high anxiety rates in Chinese children, many Asian Americans have negative
attitudes towards seeking help through therapy (Kim & Omizo, 2003). People in some Asian
cultures feel elevated shame and stigma related to anxiety and other mental health disorders.
External shame and social stigma of mental health problems is more prevalent in Asian cultures
than White American culture. Typically, individuals of Asian cultures also disclose less, fear
breaches of confidentiality, and tend to withhold pain rather than express it (Kim & Omizo,
2003).
Friedman (2001) explains that in a simple sense, anxiety can be thought of as “a
descriptive label for how one feels” (p. 38). Thus, what makes up anxiety is affected by
numerous variables such as precursor occurrences, personal evaluation of these occurrences, self
and others’ reactions to these occurrences, physiological reactivity, and the labeling of reactions
by oneself and others. From a cross-cultural approach, people’s labeling of their reactions and
feelings is reliant upon their societal reality and consequently is significantly different across
cultures (Friedman, 2001). In sum, anxiety is comprised of multiple culture-dependent
components, and perceptions of and reactions to this anxiety are greatly influenced by an
individual’s cultural outlook. Therefore, because anxiety is so culture-bound, clinicians should
be careful to gain a thorough understanding of how a client’s culture affects all aspects of his or
her anxiety.
Because anxiety is a complex construct whose expression seems to vary across cultural
groups, anxiety can be difficult and complicated to assess across cultures. Using an anxiety
assessment instrument on a cultural group for which it was not originally developed, requires
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several important considerations. One chief difficulty is the language barrier and the process and
results of translation. A general step for the cross-cultural translation method is to translate the
instrument back to the native language in which it was created after translating to a new language
to gauge if the original meanings held up. This back-translation method is necessary but not
sufficient; Even this method does not eliminate all variations given that two different languages
often do not have complementary words with identical meanings. Furthermore, if a cultural
group embodies any unique expressions of anxiety, translated versions of assessment instruments
will still fail to capture these culturally relevant expressions if the original tool did not screen for
the specific behavior (Friedman, 2001).
Another important issue to consider when assessing for GAD and anxiety across cultures
is the client’s view of self. Different cultural groups vary in their view of self on a continuum
ranging from egocentric to sociocentric (Kitayamu & Markus, 1994). Individuals from
egocentric cultures, (e.g., many westernized societies) tend to view their identities as separate
from society, whereas individuals from sociocentric cultures (e.g., traditional societies) tend to
view themselves as part of the larger group. This cultural discrepancy in self-identity will
undoubtedly affect the way language is used to express feelings such as anxiety. For instance,
individuals from Western cultures may have no problems positively expressing the presence of
anxiety on assessment instruments by endorsing items such as “I am anxious.” However,
members of other cultural groups may ignore or falsely decline such questions because anxiety
may be perceived as shameful to one’s self or family or equivalent ways of using language may
not exist (Friedman, 2001).
The overall research findings of the cultural influences on anxiety are varied and conceal
any cohesive theory. There is an undeniably need for further comparative cross-cultural research
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on the presence, conceptualization, experience, expression, and treatment approaches of GAD
and other anxiety disorders in children and adolescents. The endeavor of understanding the role
of culture in child and adolescent anxiety is only in its infancy (Albano, et al., 2003).
Relevant Ethical and Professional Issues
There are several ethical and professional issues that are relevant when treating children
and adolescents with GAD. First, some issues arise when working with children and adolescents
in general including confidentiality, the need for knowledge versus protection of child
participants, and the stigma associated with the labeling of mental health disorders. In addition,
ethical issues surround the use of exposure interventions in children with anxiety disorders.
Confidentiality
According to the American Counseling Association Code of Ethics (American
Counseling Association, 2005), Section B and the American Psychiatric Association Ethical
Principles (American Psychiatric Association, 2010), Standard 4, confidentiality is an important
issue when working with any population; however, confidentiality can be complicated when
working with minors because parents are entitled to information. As Lawrence and Kurpius
(2000) expressed, confidentiality is a very difficult ethical and legal issue because a clinician has
to decide what information to share and what not to share with a minor’s parents or guardians.
In most cases, informed parental consent must be attained for a minor to enter treatment, and
parents also have a legal right to the records concerning the evaluation and treatment of a minor.
Clinicians also legally must break confidentiality for mandated protective reporting of child
abuse/neglect and duty to warn against serious threats of injury.
Despite the legally mandated protective reporting, there are three different stances
regarding confidentiality a clinician may choose when working a minor: complete
37
confidentiality, flexible confidentiality, and no guarantee of confidentiality (Lawrence and
Kurpius, 2000). Complete confidentiality excludes sharing any treatment information with
parents but is often in direct conflict with the law. Conversely, no guarantee of or limited
confidentiality, may deteriorate the foundations of trust in the therapeutic relationship leading to
premature dropouts or reluctance to enter therapy once minors understand that parents have a
right to information.
A flexible approach to confidentiality allows adaptability to various situations but places
the clinician in the vague, complicated process of trying to balance between legal and ethical
rules. Lawrence and Kurpius (2000) recommend involving the parents in the initial meeting to
create a mutual agreement concerning what specific information will be shared with them. This
process is important because it creates clear boundaries and an agreement of trust between all
three parties, which serves as an effective form of self-protection for the clinician. In addition,
involving the minor in the decision-making process can strengthen therapeutic rapport.
The Need for Knowledge Versus Protection of Child Participants
Another relevant issue is the fact that there is a need for knowledge surrounding
childhood disorders (especially anxiety disorders), but knowledge is limited by the difficultylevel of performing research on children. Knowledge regarding childhood disorders and
treatment effects progresses slowly due to the protective, conservative approach society and
researchers take when working with minors. Children need this protection because they are
unable to defend themselves (Klin & Cohen, 1994). Consequently, studies are more difficult to
achieve and researchers are more careful and take fewer risks when dealing with minors.
However, a cultural aversion toward research in children may prevent valuable information from
38
being ascertained that could contribute to increased treatment effects and reduced suffering for
children with mental health disorders.
The two ethical principles, the need for knowledge and the protection of participants,
come to a sharp dilemma when the subjects in question are children (Klin & Cohen, 1994). The
cost and benefits must be examined and balanced. As, Klin and Cohen (1994) asserted, research
and clinical practice with children should uphold the highest ethical standards; however, the field
should not allow these principles to serve as a basis for inaction and ignorance.
The Stigma Created by Labeling Youth with Mental Health Disorders
An additional issue that should be taken into consideration when working with children is
the stigma that is created when labeling a youth with a mental health disorder. Social distance,
perception of threat, bias, distrust, embarrassment, and anger reflect the stigma surrounding
children with mental health disorders and their parents (Martin, Pescosolido, Olafsdottir,
McLeod, 2007). This stigma creates significant impairments for the child and the child’s
parents/family (Hinshaw, 2005). Several investigations have revealed negative effects of
labeling children with mental health disorders, and unfortunately, the individual must carry the
label and face the associated stigma throughout his/her entire life (Hinshaw, 2005).
Overall, the negative effects of the stigmatization of mental health disorders are severe
and expansive. Because diagnosis is most often required for treatment, clinicians may fear that
the given mental health label will cause just as many, or more problems throughout the child’s
life as the treatment can improve. Given the negative effects of labeling, careful consideration
should be given before diagnosing a child with a mental health disorder. As empiricallyvalidated treatments increasingly become more available, clinicians can more easily cite the
benefits of providing a diagnosis— the evidence of effective treatments. This evidence of
39
treatment benefits may then outweigh the risks and potential negative effects of stigma created
by the label.
Exposure Interventions
The use of exposure interventions creates some ethical issues because the goal of
exposure is to temporarily increase the child’s distress. Friedberg and McClure (2002)
acknowledge that some clinicians believe that exposure is unnecessarily upsetting to a child and
consider the intervention risky. However, although exposure is uncomfortable in the short term,
it has been found to offer long-term benefits (Friedberg & McClure, 2002). Exposure treatments
are commonly-used and have been widely and successfully documented in the research literature
(Eisen & Kearney, 1995). In other words, many researchers and clinicians argue that the
temporary distress experienced by the child is worth it because of the significant improvements
and eventual reductions in anxiety the treatment produces.
Research Challenges and Needs
A major challenge in the research of childhood GAD is a general lack of differentiation
between anxiety disorders. Most research combines multiple anxiety disorders in the
investigations, which clouds the results and useful conclusions that can be deduced related to
individual diagnoses. To facilitate the advancement of knowledge about childhood GAD,
research needs to quit treating anxiety as though it is a single disorder.
Continued study is important regarding the treatment of childhood GAD. As mentioned
above, most childhood anxiety treatments are not aimed specifically to treat individual anxiety
disorders but, rather, are usually used to treat a combination of anxiety disorders, often including
at least GAD, SAD, and SOP. Therefore, further research on the efficacy and effectiveness of
therapy for treating GAD as a single disorder is necessary. However, due to high comorbidity
40
rates, GAD rarely occurs in isolation. Consequently, future research should also be dedicated to
the treatment of GAD as it usually presents in practice– in conjunction with comorbid diagnoses
(e.g., depressive disorders and other anxiety disorders).
Additional research on the efficacy of exposure treatments on childhood GAD is
warranted. There is a distinct lack of literature devoted to the use of flooding techniques on
children with GAD. Although evidence has indicated the efficacy of systematic desensitization
in treating this population (Kane & Kendall, 1989), it is not yet clear whether exposure
treatments alone generate desired improvements (Eisen & Kearney, 1995). The scientific
research literature concerning play therapy in the treatment of GAD also is severely deficient.
Case studies comprise almost all literature concerning play therapy with anxious youth.
Consequently, play therapy needs to be tested through rigorous empirical research means in
order to establish any efficacy in the treatment of anxiety-laden children. Furthermore, research
concerning the pharmacological treatment of childhood GAD is needed. Although SSRIs are
considered the standard pharmacological treatment for this population, evidence supporting this
notion is somewhat limited. Most research regarding pharmacological treatment includes
participants of mixed diagnostic anxiety diagnoses, which, again, leads to difficulty
understanding how the conclusions directly relate to GAD. Overall, concerning the efficacy of
therapy on childhood GAD, future research would benefit with the selection of singular primary
GAD diagnosis in participants as well as increased sample sizes, further measures of
improvement, and long term follow-ups (Beidel & Turner, 2005).
Silverman, Pina and Viswesvaran (2008) suggested several directions for future research
concerning the treatment of childhood anxiety disorders. These suggestions include moving
beyond using waitlist control conditions to using active controls, such as pill and psychological
41
placebos or other established treatments. This action can help to promote CBT to the status of
“well-established” treatments. Other suggestions for research studies include increased focus on
developmental issues, integrated pharmacological treatments, and increased minority
representation.
Another area in which further research is needed surrounding childhood GAD is the
epidemiology and etiology of the disorder. As suggested by Costello, Egger, and Angold (2004),
studies should begin looking at the individual anxiety disorders with different manifestations in
relation to different ages and other disorders, correlates, and risk factors. Also, further
exploration of genetics, cognitive patterns, parenting styles, early experiences, and temperament
is warranted regarding the etiology of childhood GAD.
Methodological Issues
Finally, recommendations for methodological “best practices” in future research are
discussed below. First, there is a need for long-term longitudinal follow-ups of treatment
efficacy studies to track treatment effects over time. Also recommended for future treatment
efficacy studies is the use of extensive, well-rounded measures of severity and improvement,
such as diagnostic symptom criteria, clinician ratings, as well as child and parent self-report
measures. Furthermore, across all areas of childhood GAD research, increased sample sizes are
recommended to enhance statistical power of results, and lastly, the use of multiple sources of
data is recommended in research concerning the assessment of childhood GAD.
Conclusion
Generalized Anxiety Disorder in children and adolescents is a widespread, debilitating
disorder. The disorder is characterized by excessive worry and physiological arousal symptoms
and is often accompanied by comorbid mental health disorders, most commonly other anxiety
42
disorders and depression. Assessment and measurement of GAD in youth can be challenging but
is aided by the use of a multifaceted approach and assorted methods of assessment (e.g., clinical
interview, checklist measures, and behavioral observation).
CBT is empirically validated and the most commonly-used treatment for GAD in
children. Both individual and group CBT formats are efficacious and focus upon altering
behavior and thought patterns by implementing relaxation, exposure, and cognitive restructuring.
Family- and parent-based treatments are other interventions used to treat childhood anxiety that
focus on improving family communication and parental reinforcement and discipline techniques.
Although there is little empirical evidence addressing its efficacy, play therapy is another method
used in the treatment of childhood GAD. Finally, pharmacological treatments, mainly SSRIs,
have been found to be successful in the treatment of GAD in children and adolescents; however,
additional research is necessitated in all treatments modes.
Cultural considerations involving GAD in children include cross-cultural differences in
the manifestations of anxiety and self views. In addition, ethical issues concerning
confidentiality, protection of minors, stigma, and exposure interventions are present when
working with this population. Lastly, a great deal of additional research covering all aspects of
GAD in children and adolescents is needed.
References
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J.
Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 279-329). New York:
Guildford Press.
American Counseling Association. (2005). Code of ethics and standards of practice. Alexandria,
VA: Author.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders
(3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders
(3rd ed., rev.). Washington, DC: Author.
American Psychiatric Association. (2010). Ethical principles of psychologist and code of
conduct. Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: Author.
Barrett, P. M. (1998). Evaluation of cognitive-behavioral group treatments for childhood anxiety
disorders. Journal of Clinical Child Psychology, 27, 459-468. doi:
10.1207/s15374424jccp2704_10
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.).
New York: Guildford Press.
Barlow, D. H., & Durand, V. M. (1995). Abnormal psychology: An integrative approach. Pacific
Grove, AC: Brooks/Cole.
Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled
trial. Journal of Consulting and Clinical Psychology, 64, 333-342.
Beidel, D. C. & Turner, S. M. (2005). Childhood anxiety disorders: A guide to research and
treatment. New York: Routledge.
Ben-Amitay, G., Rosental, B., & Toren, P. (2010). Brief parent-child group therapy for
childhood anxiety disorders: A developmental perspective on cognitive-behavioral group
treatment. International Journal of Group Psychotherapy, 60, 389-406. doi:
10.1521/ijgp.2010.60.3.389
Bernstein, G. A., & Borchardt, C. M. (1991). Anxiety disorders of childhood and adolescents: A
critical review. Journal of the American Academy of Child and Adolescent Psychiatry,
30, 519-532.
Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., Baugher, M. (1999).
Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders
(SCARED): A replication study. Journal of the American Academy of Child &
Adolescent Psychiatry, 38, 1230-1236.
Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., Neer, S. M. (1997).
The screen for child anxiety related emotional disorders (SCARED): Scale construction
and psychometric characteristics. Journal of the American Academy of Child &
Adolescent Psychiatry, 36, 545-553.
Birmaher, B., Axelson, D. A., Monk, K., Kalas, C., Clark, Duncan B., Ehmann, M., Bridge, J.,
Heo, J., & Brent, D. A. (2003). Fluoxetine for the treatment of childhood anxiety
disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 415423.
Blumberg, S. H., & Izard, C. E. (1986). Discriminating patterns of emotions in 10- and 11 -yearold children's anxiety and depression. Journal of Personality and Social Psychology, 51,
852-857.
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and
generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.),
Generalized anxiety disorder: Advances in research and practice (pp. 70-108). New
York: Guilford Press.
Boschen, M. J., & Casey, L. M. (2008). The use of mobile telephones as adjuncts to cognitive
behavioral psychotherapy. Professional Psychology: Research and Practice, 39, 546-552.
doi: 10.1037/0735-7028.39.5.546
Boston, M., Lush, D., & Grainger, E. (1991). Evaluation of psychoanalytic psychotherapy with children:
Therapists’ assessments and predictions. Psychoanalytic Psychotherapy, 5, 191-234.
Brown, T. A. (1999). Generalized anxiety disorder and obsessive-compulsive disorder. In T. Million, P.
H. Blaney, & R. D. Davis (Eds.), Oxford textbook of psychopathology (pp. 114-125). New York:
Oxford University Press.
Callahan, C. (2008) Dialectical Behavior Therapy: Children and Adolescents. Eau Claire,
Wisconsin: PESI, LLC.
Chorpita, B. F., Yim, L., Moffitt, C. Umemoto, L.A., Francis, S. E. (2000). Assessment of
symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and
depression scale. Behavior Research and Therapy, 35, 835-855.
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric
evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316-336.
Cobham, V. E. (2003). Evaluation of a brief child-focused group-based intervention for anxietydisordered children. Behaviour Change, 20, 109-116. doi: 10.1375/bech.20.2.109.24838
Costello, E. J., Egger, H. L., Angold, A. (2004). Developmental epidemiology of anxiety
disorders. In T. H. Ollendick & J. S. March (eds.), Phobic and anxiety disorders in
children and adolescents: A clinician’s guide to effective psychosocial and
pharmacological interventions (pp. 61-91). New York: Oxford University Press.
Dong, Q., Yang, B., & Ollendick, T. H. (1994). Fears in Chinese children and adolescents and
their relations to anxiety and depression. Journal of Child Psychology and Psychiatry, 35,
351-363.
Eisen, A. R., & Kearney, C. A. (1995). Practitioner’s guide to treating fear and anxiety in
children and adolescents: A cognitive-behavioral approach. Northvale NJ: Aronson.
Flannery-Schroeder, E. C. (2004). Generalized anxiety disorder. In T. L. Morris & J. S. March
(Eds.), Anxiety disorders in children and adolescents (2nd ed., pp. 125-140). New York:
Guilford Press.
Flannery-Schroeder, E., Sieberg, C. B., & Gosch, E. A. (2007). Cognitive-behavior group treatment for
anxiety disorders. In R. W. Christner, J. L. Stewart, A. Freeman, (Eds.), Handbook of cognitivebehavior group therapy with children and adolescents: Specific settings and presenting problems
(pp. 199-239). New York: Routledge/Taylor & Francis Group.
Friedberg, R. D., Crosby, L. E., Friedberg, B. A., Rutter, J. G., & Knight, K. R. (1999). Making
cognitive behavioral therapy user-friendly to children. Cognitive and Behavioral
Practice, 6, 189-200.
Friedberg, R. D., McClure, J. M. (2002). Clinical practice of cognitive therapy with children and
adolescents: The nuts and bolts. New York: Guildford Press.
Friedberg, R. D., McClure, J. M., Garcia, J. H. (2009). Cognitive Therapy Techniques for
Children and Adolescents: Tools for Enhancing Practice. New York: Guildford Press.
Friedberg, R. D., McClure, J. M., Wilding, L., Goldman, M. L., Long, M. P., Anderson, L., &
DePolo, M. R. (2003). A cognitive-behavioral skills training group for children
experiencing anxious and depressive symptoms: A clinical report with accompanying
descriptive data. Journal of Contemporary Psychotherapy, 33(3), 157-175. doi:
10.1023/A:1023917518462
Friedman, S. (2001). Cultural issues in the assessment of anxiety disorders. In M. Antony, S.
Orsillo, & L. Roemer (Eds.), Practitioner's guide to empirically based measures of
anxiety (pp. 37-41). Dordrecht, Netherlands: Kluwer Academic Publishers.
Children’s fears and anxieties. (2004, November). Harvard Mental Health Letter, 21, 1-4.
Greco, L. A., & Morris, T. L. (2004). Assessment. In T. L. Morris & J. S. March (Eds.), Anxiety
disorders in children and adolescents (2nd ed., pp. 98-121). New York: Guilford Press.
Grills-Taquechel, A. E., Ollendick, T. H., & Fisak, B. (2008). Reexamination of the MASC
factor structure and discriminant ability in a mixed clinical outpatient sample. Depression
and Anxiety, 25, 942-950. doi: 10.1002/da.20401
Hinshaw, S. P. (2005). The stigmatization of mental illness in children and parents:
Developmental issues, family concerns, and research needs. Journal of Child Psychology
and Psychiatry, 46, 714–734. doi: 10.1111/j.1469-7610.2005.01456.x
Horwath, E., & Weissman, M. M. (1997). Epidemiology of anxiety disorders across cultural
groups. In S. Friedman (Ed.), Cultural issues in the treatment of anxiety (pp. 21-39). New
York: Guilford Press.
Hoehn-Saric, R., Hazlett, R. L. & McLeod, D. R. (1993). Generalized anxiety disorder with early
and late onset of anxiety symptoms. Comprehensive Psychiatry, 34, 291-297.
House, A. E. (2002a). DSM-IV Diagnosis in the Schools (rev.). New York: Guilford.
House, A. E. (2002b). The First Session with Children and Adolescents: Conducting a
Comprehensive Mental Health Evaluation. New York: Guilford.
Kagan, J. (1997). Temperament and the reactions to unfamiliarity. Child Development, 68, 139143.
Kane, M. T., Kendall, P. C. (1989). Anxiety disorders in children: A multiple-baseline evaluation
of a cognitive-behavioral treatment. Behavior Therapy, 20, 499-508. doi: 10.1016/S00057894(89)80129-7
Kearney, C. A., & Silverman, W. K. (1990). A preliminary analysis of a functional model of
assessment and treatment for school refusal behavior. Behavior Modification, 14, 340366. doi: 10.1177/01454455900143007
Kendall, P. C. (1992). Coping cat workbook. Ardmore, PA: Workbook Publishing.
Kendall, P. C. (1991). Guiding theory for treating children and adolescents. In P. C. Kendall
(Ed.), Child and adolescent therapy: Cognitive behavioral procedures (pp. 3-24). New
York: Guilford Press.
Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial.
Journal of Consulting and Clinical Psychology, 62, 100-110.
Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam-Gerow, M., Henin, A., &
Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical
trial. Journal of Consulting and Clinical Psychology, 65, 366-380.
Kendall, P. C., Hudson, J. L., Gosch, E., Flannery-Schroeder, E., & Suveg, C. (2008). Cognitivebehavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and
family modalities. Journal of Consulting and Clinical Psychology, 76, 282-297.
Kendall, P. C., Kane, M., Howard, B., & Siqueland, L. (1990). Cognitive-behavioral therapy for
anxious children: Treatment manual. Ardmore, PA: Workbook Publishing.
Kendall, P. C., Pimentel, S., Rynn, M. A., Angelosante, A., & Webb, A. (2004). Generalized
Anxiety Disorder. In T. H. Ollendick & J. S. March (Eds.), Phobic and anxiety disorders
in children and adolescents: A clinician’s guild to effective psychosocial and
pharmacological interventions (pp. 334-380). New York: Oxford University Press.
Kim, B. S. K. & Omizo, M. M. (2003). Asian cultural values, attitudes toward seeking
professional psychological help, and willingness to see a counselor. The Counseling
Psychologist, 31, 343-361. doi: 10.1177/0011000003031003008
Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003).
Prior juvenile diagnoses in adults with mental disorder: Developmental follow-back of a
prospective-longitudinal cohort. Archives of General Psychiatry, 60, 709-717. doi:
10.1001/archpsyc.60.7.709
Kirmayer, L. J. (1997). Culture and anxiety: A clinical and research agenda. In S. Friedman,
(Ed.), Cultural issues in the treatment of anxiety. (pp. 225-251). New York, Guilford.
Kitayamu, S., & Markus, H. R. (Eds.). (1994). Emotion and culture: Empirical studies of mutual
influence. Washington, DC: American Psychological Association.
Klin, A. & Cohen, D. J. (1994). The immorality of not-knowing: The ethical imperative to
conduct research in child and adolescent psychiatry. In J. Y. Hattab (Ed.), Ethics & child
mental health (pp. 217-232). Jerusalem, Israel: Gefen Publishing House.
Koeppen, A. S. (1974). Relaxation training for children. Elementary School Guidance and
Counseling, 9, 14-21.
Kovacs, M., Gatsonis, C., Paulauskas, S. L., & Richards, C. (1989). Depressive-disorders in
childhood: IV. A longitudinal-study of co-morbidity with and risk for anxiety disorders.
Archives of General Psychiatry, 46, 776-782.
Kratochvil, C., Kutcher, S., Reiter, S., & March, J. S. (1999). Pharmacotherapy of pediatric anxiety
disorders. In S. W. Russ & T. Ollendick (Eds.), Handbook of psychotherapies with children and
families (pp. 345-366). New York: Kluwer Academic.
Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol-problems
and the anxiety disorders. American Journal of Psychiatry, 147, 685-695.
Last, C. G., Hersen, M., Kazdin, A. E., Finkelstein, R., & Strauss, C. C. (1987). Comparison of
DSM-III separation anxiety and overanxious disorders: Demographic characteristics and
patterns of comorbidity. Journal of the American Academy of Child & Adolescent
Psychiatry, 26, 527-531.
Last, C. G., Strauss, C. C., & Francis, G. (1987). Comorbidity among childhood anxiety
disorders. Journal of Nervous and Mental Disease, 175, 726-730.
Lawrence, G. & Robinson Kurpius, S., E. (2000). Legal and ethical issues involved when counseling
minors in nonschool settings. Journal of Counseling & Development, 78, 130-136.
Lumpkin, P. W., Silverman, W. K., Weems, C. F., Markham, M. R., & Kurtines, W. M. (2002). Treating
a heterogeneous set of anxiety disorders in youths with group cognitive behavioral therapy: A
partially nonconcurrent multiple-baseline evaluation. Behavior Therapy, 33, 163-177. doi:
10.1016/S0005-7894%2802%2980011-9
Lyness, D. (1993). Mastery of childhood fears? In C. E. Schaefer (Ed.). The Therapeutic Powers of Play
(pp. 309-322). Northvale, NJ: Jason Aronson.
Maid, R., Smokowski, P., & Bacallao, M. (2008). Family treatment of childhood anxiety. Child
& Family Social Work, 13, 433-442. doi: 10.1111/j.1365-2206.2008.00574.x
March, J. S., & Albano, A. M. (1996). Assessment of anxiety in children and adolescents. In L.
Dickstein, M. B. Riba, & J. M. Oldham (Eds.), American Psychiatric Press Review of
Psychiatry, Vol.15 (pp. 405-427). Washington, DC: American Psychiatric Press.
March, J. S., Parker, J. D. A., Sullivan, K., Stallings, P., & Conners, C. K. (1997). The
Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and
validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 554565.
Martin, J. K., Pescosolido, B. A., Olafsdottir, S., & McLeod, J. D. (2007). The construction of
fear: Americans’ preferences for social distance from children and adolescents with
mental health problems. Journal of Health & Social Behavior, 48, 50-67
McCrae, R. R. & John, O. P. (1992). An introduction to the five-factor model and its applications.
Journal of Personality, 60, 175–215. doi:10.1111/j.1467-6494.1992.tb00970.x
McMenamy, C. & Katz, R. C. (1989). Brief parent-assisted treatment for children's nighttime
fears. Journal of Developmental & Behavioral Pediatrics, 10,145-148
Moore, P. S., March, J. S., Albano, A. M., & Thienemann, M. T. (2010). Anxiety Disorders in
Children and Adolescents. In D. J. Stein, E. Hollander, & B. O. Rothbaum (Eds.),
Textbook of anxiety disorders (2nd ed.). Washington, DC: American Psychiatric
Publishing.
Moore, P. S., Whaley, S. E. & Sigman, M. (2004) Interactions between mothers and children:
Impacts of maternal and child anxiety. Journal of Abnormal Psychology, 113, 471–476.
doi: 10.1037/0021-843X.113.3.471
Morris, R. J., & Kratochiwill, T. R. (1983). Treating children’s fears and phobias: A behavioral
approach. New York: Pergamon.
Muris, P., Mayer, B., Bartelds, E., Tierney, S., & Bogie, N. (2001). The revised version of the screen for
child anxiety related emotional disorders (SCARED-R): Treatment sensitivity in an early
intervention trial for childhood anxiety disorders. British Journal of Clinical Psychology, 40, 323336.
Muris, P., Meesters, C., Merckelbach, H., Sermon, A., & Zwakhalen, S. (1998). Worry in
Normal Children. Journal of the American Academy of Child & Adolescent Psychiatry,
37, 703-710.
Muris, P., Meesters, C., & van Melick, M. (2002). Treatment of childhood anxiety disorders: A
preliminary comparison between cognitive-behavioral group therapy and a psychological placebo
intervention. Journal of Behavior Therapy and Experimental Psychiatry, 33, 143-158. doi:
10.1016/S0005-7916%2802%2900025-3
Muris, P., Merckelbach, H., Ollendick, T. H., King, N. J., Meesters, C., van Kessel, C. (2002).
What is the Revised Fear Survey Schedule for Children measuring? Behaviour Research
and Therapy, 40, 1317-1326.
Neal, A. M., Lilly, R. S., and Zakis, S. (1993). What are African American children afraid of? A
preliminary study. Journal of Anxiety Disorders, 7, 129-139.
Newman, M. G. (1999). The clinical use of palmtop computers in the treatment of generalized
anxiety disorder. Cognitive and Behavioral Practice, 6, 189-200.
Newman, M. G., Consoli, A. J., & Taylor, C. B. (1999). A palmtop computer program for the
treatment of generalized anxiety disorder. Behavior Modification, 23, 597-619.
Nichols, M. P., & Schwartz, R. C. (2004) Family therapy: Concepts and methods (6th ed.).
Boston, MA: Pearson Education, Inc.
Ollendick, T. H. (1983). Reliability and validity of the Revised Fear Survey Schedule for
Children (FSSC-R). Behaviour Research and Therapy, 23, 465-467.
Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk for early-adulthood
anxiety and depressive disorders in adolescents with anxiety and depressive disorders.
Archives of General Psychiatry, 55, 56-64. doi: 10.1001/archpsyc.55.1.56
Rapee, R. M. (2000). Group treatment of children with anxiety disorders: outcome and predictors of
treatment response. Australian Journal of Psychology, 52, 125-130. doi:
10.1080/00049530008255379
Rapoport, J. L., & Ismond, D. R. (1996). DSM-IV training guide for diagnosis of childhood
disorders. New York: Brunner/Mazel.
Reaven, J.A., Blakeley-Smith, A., Nichols, S., Dasari, M., Flanigan, E., & Hepburn, S. (2009). Cognitivebehavioral group treatment for anxiety symptoms in children with high-functioning autism
spectrum disorders: A pilot study. Focus on Autism and Other Developmental Disabilities, 24,
27-37. doi: 10.1177/1088357608327666
Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A revised measure of children’s
manifest anxiety. Journal of Abnormal Child Psychology, 6, 271-280.
Roemer, L. & Medaglia, E. (2001). Generalized anxiety disorder: A brief overview and guide to
assessment. In M. Antony, S. Orsillo & L. Roemer (Eds.), Practitioner's guide to
empirically based measures of anxiety (pp. 189-210). Dordrecht, Netherlands: Kluwer
Academic Publishers.
Roemer, L.,& Orsillo, S. M. (2007). An open trial of an acceptance-based behavior therapy for
generalized anxiety disorder. Behavior Therapy, 38, 72-85. doi:
10.1016/j.beth.2006.04.004
Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based
behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled
trial. J Consult Clinical Psychology, 76, 1083–1089. doi:10.1037/a0012720.
Rynn, M. A., Siqueland, L., & Rickels, K. (2001). Placebo-controlled trial of sertraline in the
treatment of children with generalized anxiety disorder. The American Journal of
Psychiatry, 158, 2008-2014.
Schaefer, C. E. (1993). What is play and why is it therapeutic? In C. E. Schaefer (Ed.). The Therapeutic
Powers of Play (pp. 1-16). Northvale, NJ: Jason Aronson.
Shortt, A. L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the FRIENDS Program: A cognitivebehavioral group treatment for anxious children and their parents. Journal of Clinical Child
Psychology, 30, 525-535. doi: 10.1207/S15374424JCCP3004_09
Silverman, W., & Kearney, C. (1991). The nature and treatment of childhood anxiety.
Educational Psychology Review, 3(4), 335.
Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Lumpkin, P. W., & Carmichael, D. H.
(1999). Treating anxiety disorders in children with group cognitive-behavioral therapy: A
randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 995-1003. doi:
10.1037/0022-006X.67.6.995
Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Rabian, B., & Serafini, L. T. (1999).
Contingency management, self-control, and education support in the treatment of childhood
phobic disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67,
675-687. doi: 10.1037/0022-006X.67.5.675
Silverman, W. K., La Greca, A. M., & Wasserstein, S. (1995). What do children worry about?
Worries and their relation to anxiety. Child Development, 66(3), 671-686.
Silverman, W. K., & Ollendick, T. H. (2005). Evidence-Based Assessment of Anxiety and Its
Disorders in Children and Adolescents. Journal of Clinical Child and Adolescent
Psychology, 34, 380-411. doi: 10.1207/s15374424jccp3403_2
Silverman, W. K., Pina, A. A., Viswesvaran, C. (2008). Evidence-based psychosocial treatments
for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child &
Adolescent Psychology, 37, 105–130. doi: 10.1080/15374410701817907
Spence, S. H., & Donovan, C. (2000). The treatment of childhood social phobia: The effectiveness of a
social skills training-based: Cognitive-behavioural Intervention, with and without parental
involvement. Journal of Child Psychology & Psychiatry, 41, 713-726. doi: 10.1111/14697610.00659
Spielberger, C. D. (1973). Manual for the state-trait anxiety inventory for children. Palo Alto, CA:
Consulting Psychologists Press.
Thompson, R.A. (2001) Childhood anxiety disorders from the perspective of emotion regulation
and attachment. In M. W. Vasey & M. R. Dadds (Eds.), The developmental
psychopathology of anxiety (pp. 160–182). New York: Oxford University Press.
Tracey, S. A., Chorpita, B. F., Douban, J., & Barlow, D. H. (1997). Empirical evaluation of
DSM-IV generalized anxiety disorder criteria in children and adolescents. Journal of
Clinical Child Psychology, 26, 404-414.
Vasey, M. W., & Daleiden, E. L. (1994). Worry in children. In G. Davey & F. Tallis (Eds.),
Worrying: Perspectives on theory, assessment, and treatment (pp. 185-207). West
Sussex, England: John Wiley & Sons.
Wagner, K. D. (2001). Generalized anxiety disorder in children and adolescents. Psychiatric
Clinics of North America, 24, 139-153.
Watson, D., Clark, L. A., & Carey, G. (1988). Positive and negative affectivity and their relation
to anxiety and depressive disorders. Journal of Abnormal Psychology, 97, 346-353.
Weems, C. F., Silverman, W. K., La Greca, A., M. (2000). What do youth referred for anxiety
problems worry about? Worry and its relation to anxiety and anxiety disorders in children
and adolescents. Journal of Abnormal Child Psychology: An official publication of the
International Society for Research in Child and Adolescent Psychopathology, 28, 63-72.
doi: 10.1023/A:1005122101885
Werry, J. S. (1991). Overanxious Disorder: A review of its taxonomic properties. Journal of the
America Academy of Child and Adolescent Psychiatry, 30, 533-544.
Wolfe, V. V., Finch, A. J., Jr., Saylor, C. E, Blount, R. L., Pallmeyer, T. P., & Carek, D. J.
(1987). Negative affectivity in children: A multitrait-multimethod investigation. Journal
of Consulting and Clinical Psychology, 55, 245-250.
Wood J. J., & McLeod, B. D. (2008). Child anxiety disorders: A family-based treatment manual
for practitioners. New York: W. W. Norton & Company.
Wood, J.J., McLeod, B.D., Sigman, M., Hwang,W. & Chu, B.C. (2003). Parenting and childhood
anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology
and Psychiatry, 44, 134–151.