BHIPP Bulletin

Volume 8, Issue 9

March 2023

This month's BHIPP Bulletin is a contribution from

Rick Ostrander, EdD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine,

Founder of Pediatric Medical Psychology Program at Johns Hopkins Children's Center and BHIPP Consultant.

The International Classification of Diseases (ICD; World Health Organization, 1993) and Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnostic systems distinguish various types of anxiety disorders, including: generalized anxiety disorder, panic disorder, social anxiety disorder, separation anxiety disorder, agoraphobia, specific phobias, and selective mutism. Anxiety disorders are among the most common psychiatric disorders, occurring in 6.5% of all children and adolescents (Polanczyk et. al., 2015). Although anxiety disorders are common, some level of anxiety may be developmentally normal. Therefore, distinguishing developmentally appropriate worries and fears from anxiety disorders is an important first step in arriving at a diagnosis. For example, children in grade school commonly have worries about injury and natural events. Whereas when young people approach adolescence, they typically have worries and fears related to health concerns, school performance, and/or social competence (Beesdo et. al., 2009). The best way to distinguish normal and transitory anxiety from pathological anxiety requires primary care providers to be mindful as to whether the level of anxiety is severe (e.g., clinically high levels of anxiety reflected on rating scales), persistent (e.g., continuously present over time and/or settings), and has an associated impairment (e.g., health, academic, social). Although anxiety disorders are common, they often go untreated; in fact, the average delay from onset to treatment varies from 9 to 23 years (Wang et. al., 2005).

Current treatments for anxiety disorders in this age group include behavioral therapy, cognitive behavioral therapy (CBT), and/or medication. However, the combination of both CBT and medication is significantly better than either intervention alone (Walkup et. al., 2008). Of note, therapeutic approaches involving psychopharmacology can be very helpful in treating anxiety disorders, and primary care providers are critical to directly providing these treatments. Most of the psychosocial treatments are typically provided by therapists through individual or group treatments; however, there is emerging research that would suggest that some of the CBT interventions can be provided indirectly and through parental and school involvement.

Interventions involving CBT include an array of skills; some target changing ways of thinking, while others are more instrumental and focus on behavioral considerations linked to anxiety. Given the rapid changes in neurocognitive development over childhood and adolescent years, it is understandable why young children may be more responsive to behavioral interventions than the cognitive skills associated with CBT (Ginsburg & Smith, 2022). With younger children, CBT can be effective by working directly with parents alone (Cartwright-Hatton, Reynolds & Wilson, 2011), with the focus on changing how they react to their child’s anxiety. While many teachers have the skillset to help address anxiety concerns, they may need more training to provide the type of treatment these children need. Still, school-based intervention for anxiety can result in improved detection and better generalization of skills, and thus represents a promising option for addressing excessive anxiety and disparities in care (Ginsburg & Smith, 2022).

What To Consider When Selecting Interventions and Supports

Behavioral Avoidance

Behavioral avoidance is an important factor to consider when selecting an intervention strategy. Behavioral avoidance is when a patient avoids situations that make them feel fearful. Because avoidance leads to almost immediate fear reduction, avoidance reinforces anxiety and related behaviors, a process referred to as negative reinforcement. The more a child stays away from the feared object or situation, the more likely the child's fear will not go away. Thus, in considering intervention strategies, it is helpful to carefully assess the extent of the child's behavioral avoidance. Some guiding questions include the following:

• What is the child avoiding? (e.g., object, situation, place, person)
• What setting is the child avoiding? (e.g., school, home, afterschool activities)
• When is the child avoiding? (e.g., only upon confrontation with the feared object or situation; upon anticipation of confrontation; on school days only)
• Who or what helps to reduce the child's avoidance? (e.g., parents, siblings, pet, stuffed animal, cell phone)

How Do Others React to the Child's Fears, Worries or Anxieties?

The ways in which prominent people in a child's life react to the child's fear or anxiety can help foster fears, phobias and anxiety. If caregivers allow the child to avoid the feared situation, the child's avoidant behavior will be made worse. For example, when parents leave work early to pick up the child or sleep with the child at bedtime, they are accommodating the fear in ways that may unintentionally increase and prolong the child’s anxiety (Lebowitz et. al., 2013). Accommodations by teachers are also common, such as when a child with a phobia of bugs is allowed indoor recess or a child who fears crowds or loud noises is excused from school assemblies. At the same time, if caregivers or teachers encourage the child to approach the feared object or situation, the child is more likely to learn to ‘face their fears'. Therefore, when selecting intervention strategies, it is helpful to assess whether parents and teachers accommodate the anxious child. Consider the following questions:

• How do parents and teachers participate in the child's phobic behaviors?
• To what extent do they assist the child in avoiding anxiety provoking situations?
• Do caregivers enable behaviors related to the child's phobia?
• What modifications do parents and teachers make in relation to the child's phobic behaviors?
• Do they take on the child's responsibilities or change family or class schedules and routines?

Recommendations:

Many times, fears resolve on their own, but there are ways that parents can help ensure that the fear will not develop into a phobia or disabling anxiety. When adults respond inappropriately, children's fears may be reinforced and eventually develop into phobias or more extreme anxiety. It is therefore important for parents to talk appropriately about situations that might be anxiety-provoking. There have been several well researched interventions to prevent or treat children suffering from anxiety, fears and phobias (Creswell, Waite & Hudson, 2020; Ginsburg & Smith, 2023; Lebowitz & Omer, 2013; Silverman & Kurtines, 1996). Here are some of the recommendations that primary care providers can suggest that will help prevent phobic or fear reactions from escalating and/or will help specifically address anxiety that is more chronic or persistent.

How to Prevent Anxiety Reactions from Developing:

1. Parents should be encouraged to model appropriate reactions to anxiety provoking circumstances. For example, parents can acknowledge the anxiety but also narrate a productive way of dealing with the situation. (e.g., “The dark sometimes makes me nervous, but it is the same old living room, the lights are just out.”) 

2. Encourage parents to be mindful about media exposure, especially exposure to violent or sensational news accounts. 

3. Encourage parents to observe the child's reaction to potentially frightening situations before they react. Rather than showing concern or anxiety themselves, the caregiver should be prompted to discuss the scary event in a way that moderates the child's reactions.

4. Caregivers can be encouraged to help anxious children understand the distinction between remotely possible events and probable events. For example, it is possible that some animals bite and could carry rabies, but the probability of the family pet biting and carrying rabies is low.

5. Encourage caregivers to support a child’s approach behaviors and discourage avoidant behaviors. As soon as a parent notices that a child does not want to return to a situation or wants to avoid a situation, take the child to that situation and let them see and learn that the situation is safe. To borrow an old saying, ‘If you fall off the bike, it is important to get right back on’.



Specific Interventions for Anxieties and Phobias:

1. Reduce the child's avoidant behavior through gradual exposure. Behavioral exposure, or put another way, ‘facing your fears’, is one of the most effective ways to reduce fear of objects and situations. However, abrupt exposure to things or circumstances that are anxiety provoking risks flooding the child with anxiety and could do more harm than good. Therefore, the process of exposure should be implemented in a manner that is incremental. 

• The first step is to work with the child to develop a ‘fear ladder'. The fear ladder breaks down the fear-provoking situation by arranging it in order from most to least anxiety-provoking. For example, on a scale of 1 to 10, the child may say that being called upon in class is most scary (10), entering the classroom is less scary (7)... and seeing a picture of the school is only a tiny bit scary (1).
• It is also important to explain the benefits of facing the fear. Therefore, briefly discuss how the phobia is currently limiting the child's fun. Give some specific examples and highlight how aspects of life will improve if the child can better manage the phobia (e.g., Being in class will allow you to see your friends). Also emphasize that the strategy of ‘facing your fears’ really works if the child tries it. 
• Build on small successes and do not surprise the child with an exposure. It is essential that the child remains motivated and accumulates positive experiences in this process. Therefore, while facing one’s fears should elicit some fear arousal, it should not be overwhelming.
•  The first exposure starts with the bottom step of the ladder (e.g., looking at a picture of the school). When the child successfully looks at the picture, praise the effort of facing the fear and get the child’s permission to move on to the next step in the ladder.  
• Move up the ladder in accordance with what the child can manage. If you notice that an exposure seems too difficult, you are probably moving up the ladder too quickly. It is okay to repeat the same exposure until the child feels comfortable or to temporarily move down the ladder to repeat an earlier success.
• Be generous with effective praise. Facing fears is often highly challenging, so be sure to praise the child for the behavioral steps and efforts.
• Pay attention to generalizations. It is important to generalize the exposure. Caregivers should be encouraged to reward the practice; likewise, they should be encouraged to ask the child to face objects or situations in different settings, using the same process.

2. It is also essential to encourage caregivers to reduce their accommodations of the child's phobia. As a first step, inquire about how parents or teachers accommodate the feared object or situation. From there, encourage the caregivers or teacher to focus on their behavior rather than the child and their anxiety reactions. For example, rather than crossing the street to avoid someone walking their dog, the parent and child can approach dog walkers at an incrementally closer distance. This way, the child learns that they can come close to a tethered dog without anything bad happening. Eventually, petting a friendly dog should be the goal. With children that have many things that scare them, it is crucial to not change everything at once but to pick the circumstances that are most important first. It is also important to praise the child all along the way.

3. Parents and teachers should be encouraged to challenge the child's thinking processes. For example, a child with a dog phobia may have the negative thought that "This dog will bite me." Help the child consider more adaptive thoughts such as "I have never been bitten by a dog before, so there is no reason to believe that I will now."

If the recommendations above do not seem to reduce the child's avoidance and phobias, it may be necessary to seek professional help. Also, if the child is stuck developmentally because of a phobia-related impairment, it may indicate the need for professional assistance. For example, impaired academic functioning, restricted or impaired peer interactions, disruptions in family activities, or high levels of personal distress may also be reasons for parents to seek out professional help. In these cases, it is important to consult with a mental health professional who has experience treating phobias using supported interventions, such as behavioral or cognitive–behavioral procedures.

Recommended Resources:

https://www.nimh.nih.gov/health/topics/anxiety-disorders

• The National Institute of Mental Health describes the training, research, and clinical services that are available. It also provides a good summary of cause and treatment of anxiety disorders and phobias.

https://effectivechildtherapy.fiu.edu/course/index.php?categoryid=6

• Florida International University (Center for Children and Families) provides training tapes in evidence-based psychosocial treatment for mental health professionals.

Lebowitz, E. R., & Omer, H. (2013). Treating childhood and adolescent anxiety: A guide for caregivers. Hoboken, NJ: John Wiley & Sons. https://onlinelibrary.wiley.com/doi/book/10.1002/9781118589366

• This book is a guide for caregivers on treating childhood and adolescent anxiety.



Silverman, W. K., & Kurtines, W. M. (1996). Anxiety and phobic disorders: A pragmatic approach. New York, NY: Plenum Press. https://doi.org/10.1007/978-1-4757-9212-6

• This book is for primary care providers and mental health professionals.

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

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