An Overview of Childhood Anxiety Disorders…

NERD ALERT!!! – This post is a review of old assignments & papers that all focus on a specific diagnosis. The goal of this exercise is to become more familiar with mental health diagnoses…

Anxiety Disorders – Developmental Considerations…

The anxiety disorders section of the DSM-5 Manual is arranged developmental by age of onset.  This paper focuses on a review of information from a papers on Childhood Anxiety Disorder.  Developmental delays are a key issue with childhood anxiety disorders since states of excessive anxiety can divert attention from key developmental tasks, causing problems later in life.   For example, delayed social skills, low self-worth, distorted thinking patterns, and poor emotional regulation, are common problems associated with these disorders (Ginsberg, 2007).  When you consider that some estimates of prevalence for anxiety disorders in adolescents are as high as 20% this is clearly an issue that needs to be addressed (Ginsberg, 2007; Wood, et al, 2003). Despite this fact, a clear and easy solution isn’t available.  One resource for this paper indicates that childhood anxiety disorders develop within a chaotic environment and parental symptoms of anxiety (Murray & Cooper, 2006). Temperament, and parenting styles are also key factors often mentioned predisposing children to a higher likelihood of developing these disorders (Wood, et al, 2003). Addressing all these associated factors would be essential.

So what is anxiety and exactly when does it become problematic?

According to Morrison, (2014) fear in general can be an adaptive response to danger and reflects a fight-or-flight response.  However, while fear in general is an emotional discomfort to perceived danger, anxiety is the “anticipation of a future threat” (American Psychiatric Association, 2013, p. 189).  Finally, the DSM-5 manual “anxiety disorders differ from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods…[involving an] overestimation of anxiety” (American Psychiatric Association, 2013, p. 189).  In other words, trait anxiety my be a transitory worry, the disordered variety can involve an overestimation of threat over a prolonged period of time that impedes one’s daily function. (Craske, 1999).

If one thing is clear, it is that developmental delays are a key issue with anxiety disorders.

States of excessive anxiety in childhood divert attention from key developmental tasks, causing problems later in life. For example, delayed social skills, low self-worth, distorted thinking patterns, and poor emotional regulation, are common problems associated with these disorders (Ginsberg, 2007). When you consider that some estimates of prevalence for anxiety disorders in adolescents are as high as 20% this is clearly an issue that needs to be addressed (Ginsberg, 2007; Wood, et al, 2003). Despite this fact, a clear and easy solution isn’t available. It appears, that many childhood anxiety disorders develop within a chaotic environment and parental symptoms of anxiety (Murray & Cooper, 2006). Temperament, and parenting styles are also key factors often mentioned predisposing children to a higher likelihood of developing these disorders (Wood, et al, 2003). Addressing all these associated factors would be essential.

In the following sections is a discussion of etiologies and treatments for reactive attachment disorder, separation anxiety, and selective mutism.

Reactive Attachment Disorder.

The development of early attachments are critical from the standpoint of future personality and brain development (Cornell, et al. 2008; Hardy, 2007).   Key schematic frameworks regarding perceptions of self, and the reliability of others, develop as early in infancy. Additionally, as research has shown, these understandings, define many of our future relationships (Cornell, et al, 2008). Our attachment relationships develop as a history throughout our lives.

Attachment Theory

John Bowlby’s early work on attachment theory appears to provide a good share of our theoretical understanding on this issue.   Based on his observations of a child’s relationship with caregivers, he was able to predict future personality development (Hardy, 2008).   Additionally, his research provided a description of four key attachment styles: disorganized, ambivalent, avoidant, and secure (Hardy, 2008). His observations of body language, social cues, level of interactional reciprocity, and caretaker behavior provide a clear description of these styles (Cornell, et al, 2008). Underlying these observations are key differences in a child’s perception of self in relation to others. As one article aptly puts it: “the paradoxical experience of separateness and connectedness is enduring. Indeed, human beings struggle throughout their lives with balance thing need to be alone with others.” (Corbin, 2007, 542).


According to the DSM-IV-TR describes Reactive Attachment Disorder as follows: “Markedly disturbed or developmental inappropriate social relatedness in most context evidenced before age 5 years evidenced by either (1) persistent failure to initiate and respond to most social interaction or…(2) indiscriminate sociability with marked inability to exhibit appropriate selective attachments” (Hardy, 2007, 30). Additionally, the DSM-IV-TR, goes on to say, that this criterion alone doesn’t necessarily warrant a diagnosis of Reactive Attachment. Observations of pathogenic care as observed by persistent parental disregard for child’s basic needs (Hardy, 2007).   Interestingly, while both the DSM, and psychological theory provide a good basis of understanding for attachment issues, current literature doesn’t address how their observations correlate (Cornell, et al, 2008). Further work is needed to clearly define the relationship between the DSM’s discussions of attachment issues, and relevant attachment theory. (Cornell, et al, 2008).

Etiological Factors.

“A variety of biopsychosocial conditions are affected by the processes surrounding attachment” (Corbin, 2007, 539).   The associated factors that underlie the development of reactive attachment are complex and integrated. These etiological factors include child temperament, genetics, the absence of key attachment figures, and maltreatment (Cornell, et al, 2008). Research for this paper discussed two key categories of factors which are each discussd below.

Biological Causes.  In addition to the discussion of genetic inheritance as a key factor, deviations in the brain’s structure also provide a etiological explanation (Corbin, 2007). For example, our textbook mentions key structures in the brain, associated with the development of fear-based disorders, (Blaney & Millon, 2009, 126).   While the amygdala is responsible for attending to the emotional significance of experiences, the hippocampus is vital in the development of long-term memory (Blaney & Millon, 2009).   Dysfunction in these key structures may provide an etiological understanding of this disorder.

The Parenting Relationship.  According to one resource for this paper, several theoretical perspectives exist to provide an understanding of the attachment process (Hardy, 2007, 28). On the one hand, developmental psychology points toward the development of internal working models (Hardy, 2007, 28). Other perspectives add to this, by pointing towards key alterations in brain development as a result of infant and caregiver interaction.   A caregiver’s ability to influence and maintain an infant’s affective state influences this developing brain.   From this perspective, education and parenting training are most effective.


Key interventions often proposed include cognitive behavioral interventions, addressing the attachment relationship, and social support (Hardy, 2007).   Direct interventions focused on children can work to improve any impaired social relationships, and increase functioning as well as self esteem.   Education and training for parents can help provide a better understand of the disorder with tools for managing it (Hardy, 2007).   These psychoeducational models provide a therapeutic coaching experience for parents of RAD children.   In addition to providing practical understanding, helping parents more effectively relate to RAD children are also helpful. (Cornell, 2008).

RAD vs. Separation Anxiety

While RAD is associated with a history of insufficient and neglectful care alongside emotionally withdrawn behavior (American Psychiatric Association, 2013). In contrast, Separation Anxiety Disorder (SAD) involves a recurrent distress and worry when anticipating separation (Orvashel, et al, 2001), In other words, SAD is related to fear of abandonment, and RAD involves an inability to form attachments.

RAD vs. School & Social Phobias

Orvashel, et al, (2001) describe school and social phobias in chapters nine and ten. School phobia is related to school refusal behavior and, at times, a failure to attend school consistently. In the case of social phobia the child instead has a fear of social situations and potential embarrassment. On one hand, school and social phobia are associated with a fear of a specific activity or event.   On the other hand, RAD is not associated with a fear of a specific event or thing. Instead, the unresolved fear exists to an inability to connect with others and form meaningful attachments with caregivers.


GAD is associated with an excessive and uncontrollable worry associated with an array of symptoms including irritability, sleep problems, and restlessness (American Psychiatric Association, 2013).   In contrast, excessive worry is not present in RAD, instead they are either emotionally withdrawn, or acting on unresolved fear or anger.


Orvashel, et al, (2001) describe OCD as involving intrusive and persistent thoughts that cause marked anxiety. In an effort to resolve this anxiety, individuals engage in repetitive acts as a response.   RAD does not involve either of these issues.

Suggestions for Accurate Diagnosis

Information multiple sources and contexts is important, including the child’s primary caregivers and teachers. Through case histories including academic and medical files can also provide important information.   Finally, a through longitudinal assessment of symptoms is also important. As I recall from the DSM class, all diagnoses temporally specific criterion. Additionally, the differential diagnosis appears to be based upon a careful contextualization of observations. In other words, what is the potential reason or context in which we can best understand the observed behavior?

Treatment Decision-Making

It seems that with RAD, the underlying cause is a history of abuse and neglect. On the basis of this insight, an array of developmental considerations is worth examining. Does the child have any physical or academic delays as a result of this history? What is the nature of the child’s trauma, is a PTSD diagnosis warranted? Last, but not least, it would be important to examine the child’s parents, and home environment so these factors could be included in a treatment plan as well.

Selective Mutism

Definition & Diagnosis.

“Selective mutism has been defined as the consistent failure to speak in specific social situations, in which there is an expectation for speaking” (Beare, et al, 2008, 248).   The specific criteria for the DSM-IV diagnosis are as follows:

  1. A refusal to speak in certain social situations (Kumpulainen, 2002, 176).
  2. Negatively impacted social communication and attachments (Kumpulainen, 2002, 176).
  3. Presentation of symptoms for a minimum of one month, not explainable by other associated psychiatric disorders (Kumpulainen, 2002, 176). 

Etiological Factors.

In an article titled “Selective Mutism: Causes and Interventions” by Alan Hultquist, there is an overview of literature that describes subgroups (Hultquist, 1995).   Based on an assortment of audiovisual and written observation, four types of selective mutism were discussed (Hultquist, 1995). While an in-depth discussion of this typology is beyond the scope of this paper, one thing may be noted. Underling this typology are associated etiological factors associated with each. Unhealthy symbiotic relationships with maternal figures, an extreme social phobia, passive-aggressive tendencies, or reactive post-trauma are just a few causes gleaned from this typology.

Still other research for this paper, proposes factors such as displaced hostility, an attempts to protect self-image, or socialization failures as added issues (Kumpulainen, 2002). Interestingly, these set of factors, include the interaction of child temperament with peer relationships and school officials as another observed etiological factor.


Child Therapy.

A variety of direct interventions are described in literature for this paper, including. Involving direct contact with the child, these interventions include both individual and group therapies. While group therapies involve play sessions with other children and therapists, individual direct therapy for children can include psychoanalytic therapy (Hultquist, 1995). Still, it must be noted, that psychoanalytic interventions, appear to have fallen into disfavor, due to the length and ineffectiveness of this approach (Hultquist, 1995; (Kumpulainen, 2002).

Behavioral Modification.

The most commonly cited successful form of therapy for this specific disorder, includes behavioral modification. Implemented in home and school environments, it includes interventions such as “stimulus fading, desensitization, extinction, and self modeling” (Hultquist, 1995, p103), just to name a few.

Family Therapy.

Cooperation with family members is essential to adjust the environmental factors to improve chances of recovery, (Kumpulainen, 2002). This process will need to start with an education on the nature of the disorder, (Kumpulainen, 2002).   Additionally, a thorough assessment with all family member relationships will be vital to better understand the relational dynamics in the household (Hultquist, 1995). This can provide a clearer understanding of this disorder as occurring from within a specific familial environmental context (Hultquist, 1995). Interventions can then be provided and implemented accordingly.

School Based Interventions.

Finally, brief mention must be made, on the critical need to include the school system.   Providing educational and interventional resources for key personnel, are vital in promoting recovery.

Separation Anxiety.

Description & Diagnosis

From a laymen’s perspective, separation anxiety, seems more of a normal reaction for infants and young toddlers.   How can one differentiate normal reactions to separation with those instances in which it can be considered a disorder worthy of a DSM-based diagnosis? According to one resource for this paper, a Separation Anxiety Disorder can be defined as follows:

“Separation anxiety refers to developmentally appropriate distress regarding separation from significant disorders….Separation anxiety disorder (SAD) refers to developmentally inappropriate distress for at least 4 weeks regarding separation. A diagnosis of SAD requires three of nine symptoms and interference in daily functioning.” (Tillotson, 2003, 593).

The severity of symptoms associated with SAD are highly varied from an “anticipaitory uneasiness to full-blown anxiety” (Masi, et al, 2001, 94). Additionally, this disorder often spontaneously remits, and is associated with a high occurrence of co-morbidities. It is on the basis of these facts, that one research article describes SAD as a highly unstable diagnosis (Tillotson, 2003, 596).

Etiological Factors.

A complex interplay of biological and genetic vulnerability, temperamental qualities, negative environmental influences, attachment experiences, and parental psychopathology…may induce the appearance of the disorder and influence its clinical severity. (Masi, et al, 2001, 94).

On the one hand early presentations of this disorder are said to reflect a strong biological disposition (Tillotson, 2003, 597) On the other hand, a problematic family environment and relationships are often found in those cases occurring in later childhood (Tillotson, 2003, 597). Additionally, parental psychopathology in the form of anxiety disorders can perpetuate and reinforce the condition (Masi, et al, 2001, 94).   Finally, research points toward a strong association between family disharmony and parental inconsistency as key factors associated with this disorder. (Tillotson, 2003, 597).


Psychoeducational intervention in the form of family therapy, and parenting classes are essential. A through assessment of the family relationships and overall home environment are warranted. Providing parenting classes along with an explanation of the disorder and its symptoms, also helps to mange this disorder.

Finally, a discussion of interventions can’t go without a mention of cognitive behavioral therapy. As the most often-mentioned technique for childhood anxiety disorders, it is helpful addressing faulty cognitions associated with the anxieties. Additionally, behavioral modification techniques also prove helpful in addressing key symptoms associated with this disorder.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington D.C.: Author.
Blaney, P., & Millon, T. (Eds.). (2009). Oxford textbook of psychopathology, 2nd ed. Oxford, U.K.: Oxford University Press. ISBN 978-0-19-537421-6. (BM)
Corbin, J. R. (2007). Reactive attachment disorder: A biopsychosocial disturbance of attachment. Child & Adolescent Social Work Journal, 24(6), 539-552. doi:10.1007/s10560-007-0105x
Cornell, T., & Hamrin, V. (2008) Clinical interventions for children with attachment problems. Journal of Child and Adolescent Psychiatric Nursing. 21(1), 35-47.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM5. Washington, D.C: American Psychiatric Association
Ginsburg, G. S., & Julie, N. K. (2007). Evidence-based practice for childhood anxiety disorders. Journal of Contemporary Psychotherapy, 37(3), 123-132. doi:10.1007/s10879-007-9047-z
Hardy, L. T. (2007). Attachment theory and reactive attachment disorder: Theoretical perspectives and treatment implications. Journal of Child and Adolescent Psychiatric Nursing, 20(1), 27-39. Retrieved from
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Kumpulainen, K. (2002). Phenomenology and treatment of selective mutism. CNS Drugs, 16(3), 175-180.
Masi, G., Mucci, M., & Millepiedi, S. (2001). Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management. CNS Drugs, 15(2), 93-104.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health  clinicians, 2nd ed. New York: The Guildford Press.
Murray, L., Creswell, C., & Cooper, P.J. (2009). The development of anxiety disorders in childhood: an integrative review. Psychological Medicine. 39, 1413-1423.
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization and treatment of child psychopathology. Oxford, UL: Elsevier LTD.
Wood, J., McLeod, B., Sigman, M., Hwang, W., & Chu, B. (2003). Parenting and childhood anxiety: theory, empirical findings, and future directions. Journal Of Child Psychology And Psychiatry, And Allied Disciplines, 44(1), 134-151.

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