Is the emotional response to real or perceived imminent threat. Often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors.

Is anticipation of future threat. More often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors.

Normal fears from birth to 6 months

Normal fears 7-12 months

Normal fears 1-5 years old

Normals fears for 3-5 year olds

Normal fears for 6-12 year olds

Normal fears 12-18 years old

Fear of being separated from a caregiver, fear of harm to self or caregiver when separated

Consistent reduced communication (e.g., not speaking) in at least one environment despite ability to speak

Fear of negative evaluation

Fear of a particular situation or object

Fear of the physiological sensations of anxiety and of having a panic attack

Worry about a broad range of topics

Anxiety disorder in childhood adolescents predict a range of psychiatric disorders in adulthood

◦ Normal uncertainty and anxious or insecure attachment ◦ Maintenance of symptoms conditioned by fear, reinforcement ◦ Attachment theory - insecure mother-infant attachment and maternal sensitivity each separately predicted separation anxiety in children at age 6 years

◦ Dysregulation of fear and stress response system in the brain ◦ Behavioral inhibition - genetically based temperament trait characterized by response to a new or unfamiliar situation with avoidance, distress, caution, and/or reticence.

◦ Parenting styles characterized by rejection, control, and intrusiveness are also likely related to increased anxiety in youth ◦ Parental modeling and exposure to negative information (SOC, Panic disorder, GAD)

Hallmarks of Anxiety in Children and Adolescents

Ages 8-19: GAD, panic/agoraphobia, social phobia, SAD, OCD, and physical symptoms, harm avoidance

Ages 9-18; GAD SOC, phobic disorders, SAD

Ages: 8-15; GAD, panic/agoraphobia, social phobia, SAD, OCD, and physical injury fears

Ages 2.5-6.5 (Based on the SCAS)

Ages 6-17; GAD, general and social phobia, SAD

When moderate to severe anxiety symptoms persist what SSRIs can we use and what age range?

What are the SNRIs for child and adolescents?

Benzos used in child and adolescents?

Non-benzodiazepine (0.2-0.6 mg/kg; BID or TID – indicated for OCD, GSD, SOC) SE: lightheadedness, dizziness, nausea, sedation

-Tertiary TCA (2.0-5.0 mg/kg; daily or BID – indicated for OCD and school refusal) -SE: Anticholinergic

-Tertiary TCA (2.0-5.0 mg/kg; daily or BID – indicated for GAD and panic disorder) -SE: cardiac toxicity and EKG changes

-Secondary TCA (2.0-5.0 mg/kg; daily or BID – indicated for OCD) -SE: cardiac toxicity and EKG changes

-Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached -Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. -Persistent and excessive worry about losing major attachment figures or about possible harm to them -Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. -Persistent reluctance or refusal to go out because of fear of separation. -Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. -Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. -Repeated nightmares involving separation. -Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. -The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks -The disturbance causes clinically significant distress or impairment -The disturbance is not better explained by another mental disorder

Duration of Separation Anxiety Disorder (SAD)

Epidemiology of Separation Anxiety Disorder (SAD)

Separation anxiety is a normal developmental phenomenon in

-Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. -The disturbance interferes with educational or occupational achievement or with social communication. -The duration of the disturbance is at least 1 month (not limited to the first month of school). -The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. -The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Relatively rare ◦ Prevalence between 0.03%-1% depending on the setting (e.g., clinic vs. school vs. community) Most likely to occur in young children rather than adolescents ◦ Onset usually before age 5; may not be clinically relevant until attendance in school -Common in males and females -Persistence varies; however, most outgrow -Longitudinal course is unknown

◦ Shyness ◦ Behavioral inhibition ◦ Receptive language difficulties (although still within normal range) ◦ Social isolation/anxiety

◦ Parental modeling ◦ Overprotective parenting or more controlling ◦ Genetic factors ◦ May be shared genetic factors that are associated with social anxiety disorder

Noted usually at the start of kindergarten or 1st grade ◦ Most are diagnosed between ages 3-8 -Resolves by age of 10; if continues beyond 12 years, full recoverly less likely -SM leads to complications in academic achievement and peer relationships ◦ May lead to placement in special education classes or schools -May develop social anxiety disorder in adulthood

-Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. -The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated -The social situations almost always provoke fear or anxiety. -The social situations are avoided or endured with intense fear or anxiety. -The fear or anxiety is out of proportion to the actual threat posed by the social situation/context -Must last 6 months or more

Blushing in a hallmark sign of this disorder

-Prevalence: 5% in children and 16% in youths 13-17 years -More common in girls and younger children

Prevalence: 2-5% children, 9% in adolescents ◦ Lifetime: 16%

Median age of onset: 13 years ◦ Age of onset between 8 and 15 years for 75% of individuals ◦ May follow a stressful or humiliating experience, or an experience which may require a new social role ◦ Adolescents may have broad patters of fear and avoidance, in comparison to younger children ◦ 30% experience remission of symptoms within 1 year ◦ 50% within a few years ◦ 60% without a specific treatment, it may take several years or longer

◦ Tends to begin in adolescence ◦ Stressful life events may play a role ◦ Impact functioning into adulthood if symptoms persist (Similar to SAD outcomes)

◦ Can begin at any time during development ◦ Usually associated with an unexpected panic attack or traumatic event ◦ Often resolve spontaneously ◦ Those with natural-environment type phobias tend to fare poorly and are more difficult to treat than those with animal-type phobias

Characterized by social evaluative concerns; fear that the individual makes other people uncomfortable

Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences 2. A significant maladaptive change in behavior related to the attacks

Age of onset in U.S.: 20-24 years old ◦ Small numbers in childhood, rare ◦ More common in adolescents 12-month prevalence: 2-3% in adolescents and adults in U.S. and European countries Ethnic differences within the U.S. ◦ Lower rates: Latino, African American, Caribbean blacks, and Asian Americans (0.1-0.8%) ◦ Higher rates: American Indians Male:Female ratio is 1:2 ◦ Occurs is adolescence and usually observable prior to age 14 Possibly a genetic component based on twin studies Panic disorder increases in adolescence and peaks during adulthood, often declining in the older adult If untreated, can wax and wane for years

-Natural history and course are unclear -Likely to be a chronic disorder as often co-occurring with other anxiety and mood disorders, including ADHD -Prepubertal onset usually signals greater severity -Can begin at the onset of or during an episode of major depression or SAD

-Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). -The individual finds it difficult to control the worry. -The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). -The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Common symptoms may include ◦ Nail biting ◦ Hair pulling ◦ Thumb sucking ◦ Licking around the mouth ◦ Somatic symptoms (see picture)

Average age of onset: early 30s Transient symptoms may be developing in children due to other anxiety disorders or depression Prevalence: 1 -3% in adolescents Male: Female ratio: 1:2

-Chronic disorder with low rates of full remission -Improvement is variable due to the waxing and waning nature of the disorder (with or without treatment) If diagnosed in childhood ◦ Likely due to heritable traits ◦ May exhibit more severe symptoms and impairment ◦ Increased risk for the development of a range of disorders across the life span

What phobias are equal in boys and girls?