Professor Ron Rapee Well, hello, everyone.  My name’s Ron Rapee. I’m from the Centre for   Emotional Health at Macquarie University, and  I’m going to be presenting a brief overview   of anxiety disorders in young people.  I’ll be presenting it in two parts,   in two separate videos. In this first section,  I’m going to give a broad overview of some of   the main characteristics and the risk factors for  anxiety disorders in children and adolescents,   and then in the second part,  I will talk about treatments. So, in today’s video, what I’m going  – or in the first part of the video,   what I’m going to talk about, is firstly, how  to recognise and diagnose anxiety disorders   in children and adolescents. I’ll then go on and  talk briefly about the degree of impact, or degree   of life interference, that anxiety disorders  create in children’s lives. I’ll describe some   of the demographic characteristics of anxious  children and adolescents, and then, I’ll finish   this presentation with a bit of an overview of  some of the risk factors and maintaining factors,   and I’ll finalise with an overarching model of  the theory of anxiety disorders in young people. So, when we want to diagnose anxiety  disorders in children and adolescents,   there’s a number of particular characteristics  we want to look for. Firstly, most importantly,   there’s the core features of anxiety disorders.  The core defining characteristic of an anxiety   disorder is an expectation of danger, some  form of danger or threat. In other words,   the child or the adolescent believes that they,  or someone close to them, and usually they,   are in some sort of danger or some sort of  threat is about to immediately or shortly occur. That danger or threat doesn’t necessarily  have to be physical. It could be physical   or it could be social, but there’s a wide  range of different forms of dangers and   threats that children with anxiety disorders  are concerned about, but that is the core   characteristic you need to look for. Along  with that expectation of danger or threat,   there is avoidance behaviour. The defining  characteristic, or the most – or perhaps you   might say the most fundamental characteristic of  young people with anxiety disorders is that they   avoid. That avoidance can often be subtle,  it may be hard to determine in some cases,   but it has to be there in order to  decide that this is an anxiety disorder. And finally, when you try to distinguish  an anxiety disorder, a clinical disorder,   from general, more what you might call normal  or average anxiety, one of the key defining   characteristics is the life impairment or  the life impact that the anxiety disorder   has. Parents often ask me, “How do I know if  my child has a clinical problem or if it’s   just normal anxiety?” and my response usually is,  if it’s affecting that child’s life in some way,   if it’s stopping them from being able to do what  they want, then it’s worth doing something about   it. And then I guess we might call that a  clinical problem or a clinical disorder. In addition to these core features there’s some –  a few additional characteristics that are common   in anxiety disorders, but these characteristics  are not specific to anxiety disorders and so,   they’re really not core defining features.  Things like negative expectations or worries,   a tendency to ruminate about negative things,  is very common amongst children and adolescents   with anxiety disorders, but it’s also found in  a wide range of other disorders. And similarly,   arousal symptoms, physical symptoms of excess  arousal, sweating, shaking, heart racing,   dry mouth, those sort of characteristics are  very common among children and adolescents   with anxiety disorders, but again, you’ll find  them across a range of other disorders, as well. When we’re talking about anxiety disorders,  there’s a number of specific types that are   typically found in diagnostic systems. The  DSM-5 is one of the most widely used systems   and one that I’m most familiar with, and the DSM  talks about several different types of anxiety   disorders. Among the most common include, firstly,  separation anxiety disorder. Separation anxiety   disorder refers to children or adolescents  who are worried about separating from a major   caregiver or attachment figure, and again, what  we’re looking for is a core threat belief. And so,   the threat belief that they had is often that  “When I’m separated from my caregiver something   bad will happen either to them, or to me. My  parent will be killed, a burglar will break in,   they’ll be in an accident,” something. So,  there’s a threat belief, and as a result of that,   the threat belief is, in this particular  disorder, is around fear of separating. Along with that, the avoidance, then, is a  logical concomitant of that. So logically,   these children will often avoid anything to do  with separation. They might invoid going – avoid   going to school camps, they avoid going to  school in some cases. They avoid sleeping in   their own room, they avoid sleeping at other  people’s places. They will avoid being left   alone in a wide variety of circumstances,  all because of the fear of separating. Another very common form of anxiety disorder is  generalised anxiety disorder. These are young   people who worry a great deal about general  matters. They might worry about finance – the   family finances, or their parent being unemployed.  They might worry about wars in other sar – parts   of the world, or famine in different parts of  the world. They’re worried about a whole range   of both minor and major issues, but again, there’s  that constant expectation of danger or threat. In this particular disorder, the avoidance  behaviour can often be quite subtle and   hard to determine, but it’s there. There is  still avoidance behaviour in children with   generalised anxiety disorder. One common form  of what you might call avoidance is reassurance   seeking. Many of these children constantly  ask a lot of reassurance-based questions,   and that’s because they’re avoiding  the possibility of not knowing. And so,   the avoidance, as I said, is subtle, but the  sorts of avoidance that children with generalised   anxiety disorder often gage – engage in is  avoidance about being uncertain about things,   about not knowing things, about  not being in control, and so on. And the third very common form of anxiety disorder  is social anxiety disorder. These are young   children whose basic threat belief is that “Others  will think badly of me in some way,” and so,   their core anxiety is a fear or avoidance  around being negatively evaluated. And so,   they might have fears of making  mistakes, of looking silly,   of being – doing embarrassing things, in  some way of being negatively evaluated,   and as a result they tend to avoid a wide range  of social situations that involve any sort of   potential evaluation. So, they might avoid  meeting new people, they might avoid speaking   up in class or speaking in front of people,  they might avoid going to parties, and so on. There is one other very common form of anxiety  disorder, which are the specific phobias. I add   them on almost like an afterthought, largely  because we tend not to see many specific   phobias coming in as the primary problem in  clinical practice. Specific phobias refer to   fears of a wide range of very circumscribed  situations or events, like fears of the dark,   fears of spiders and snakes, fears of loud  noises, and so on. And many kids with anxiety   disorder – with other anxiety disorders, who  come in for clinical treatment, will also have   a range of specific phobias, but it’s relatively  rare for a specific phobia alone to be the main   cause of a child coming for treatment.  It can happen, but it’s not very common. Then there are a couple of other less common  forms of anxiety disorder. Two of those,   firstly, panic disorder and agoraphobia. These  refer to people who have sudden bursts of panic   or fear that might come out of the blue, and  that involve fears that they’re going to die   or pass out. And the agoraphobic avoidance often  refers to situational avoidance around avoiding   the possibility of having a panic attack,  staying at home, avoiding shopping centres,   and so on. Now, panic disorder and agoraphobia  typically don’t begin until very late adolescence   or early adulthood, which is why they tend to  be very rare among children and adolescents,   and it’s not something you would see very  often. You can sometimes find even young   children who make criteria for these  disorders, but it is relatively rare. The other rare form that’s now included  by the DSM-5 under the anxiety disorders,   is selective mutism. Selective mutism refers  to children who, basically, don’t talk in any   threatening type of situation, and in most cases,  that’s pretty much anywhere outside the home. So,   these children tend to talk, very often, very  commonly, at home with their family and close   friends, and then as soon as any stranger comes  to the home, or as soon as they leave the home,   they stop talking, and they, basically, do  not talk at all in those situations. Extensive   research now shows that selective mutism has  a lot of commonalities, and in fact, in – many   Authors would say that they – it’s the same  thing as social anxiety disorder. And so,   social anxiety disorder and selective mutism  really go together very much hand-in-hand.  I quickly just mention two other disorders,  obsessive compulsive disorder and post-traumatic   stress disorder. Under the DSM-5, these are  no longer considered to be anxiety disorders,   technically. They are in a different section  of the DSM-5. However, many Authors and many   Researchers who work in the field of  anxiety disorders would still include them,   and there’s no doubt that these two disorders  have a lot of commonality and a lot of overlap   with the anxiety disorders, in particular,  obsessive compulsive disorder is very,   very anxiety-like in its characteristic and  responds to the same sorts of treatments. Just a quick comment before I move on, which is  that I’ve talked about each of these disorders   as rather separate things, but in fact,  overlap between them is very common. In fact,   it’s very unusual for a child who presents  with a clinical anxiety disorder to only   meet criteria for one. The – most young people  with anxiety disorders will meet criteria for   two or three or four different anxiety  disorders, and so, comorbidity is very,   very common. The anxiety disorders also  overlap with a lot of other disorders,   non-anxiety disorders. So, comorbidity  with other disorders, such as the mood   disorders and externalising disorders and  eating disorders, is also very common. So, what’s the problem with having anxiety  disorders? What’s so bad about it? Well,   the anxiety disorders actually do have a lot of  life impacts. Even though anxiety is a very common   experience and a lot of people in society will  say, “Ugh, well, who cares about anxiety? Everyone   gets anxious.” Well, it’s true, everyone does get  anxious, but when a child has an anxiety disorder,   it will affect their life in a number of ways.  Firstly, they find it personally distressing.   Most young people who have anxiety disorders don’t  want to have them, they’re not happy about it, and   they would rather that it went away. So, it’s not  a pleasant thing to have high levels of anxiety   over long periods of time. In addition, it does  affect children’s lives in many practical ways. One way is academically. There’s extensive  research showing that young people with   anxiety disorders are far more likely to be  absent from school on any given day, and so,   school attendance is dramatically reduced. They’re  also more likely to drop out of school early,   that is to terminate their schooling at the  end of – towards the latter years of schooling   earlier – in other words, not finish schooling,  more like – more so than kids with other – or   kids who don’t have mental disorders. There’s  also some strong data showing that children   with anxiety disorders have reduced academic  achievement and reduced grades. There’s a very,   very powerful study from my own country,  from Australia, in a large population survey,   showing – starting out from grade three and going  through to grade nine, longitudinally and showing   that as kids go through the grades, kids with  anxiety disorders drop gradually further and   further and further behind the rest of their  cohort. So, by the time they get to grade nine,   these kids were scoring, on academic achievement,  about two years behind the rest of their cohort. Children and adolescents with anxiety  disorders also have difficulty making   friends. They often will have some good  friends, they’re not antisocial at all,   but they have fewer friends than other kids their  age, and when they break up with a friendship,   or when their friends leave, then they have much  more difficulty making new friendships. They’re   also more likely to be rejected by their peers,  and more likely to experience peer victimisation.   In the longer term, anxiety disorders also create  risk for other problems going into adulthood. So,   children and adolescents who have anxiety  disorders are at greater risk when they   become adults at also having anxiety disorders,  having mood disorders, having suicidal action   or activities or engagement, and at  substan – having substance abuse. Okay, I’m going to go on now to talk a little bit  about some of the demographic characteristics,   some of the features of anxiety disorders, and  firstly, the prevalence. This is some data from   a study by a group, Polanczyk and colleagues,  in 2015, who did a broad meta-analysis where   they pulled together data from a large number of  population surveys from right around the world.   So, we’re looking at worldwide prevalence of  all mental disorders, and this was – this study,   they had 41 different studies from 27 different  countries, looking at young people aged between   six and 18 years. And look – you can see,  across the different mental disorders there,   that anxiety disorders, so this column here,  are the most common form of mental disorder   in children and adolescents. You can see there,  around about 6.5/7% of young people with – from   all countries across the world, meet criteria  for an anxiety disorder, and that’s more common   than all the disruptive disorders put together,  and more common than ADHD and mood disorders. When we want to look at the specific forms  of anxiety disorder, here’s some data from   the Australian Bureau of Statistics. Again, a  large population survey, I think around about   10,000 children and adolescents, looking at the  specific disorders, and in this particular case,   you can see, firstly, interestingly, that  the Australian data showed about 7% of four   to 17 year-olds have an anxiety disorder,  which you can see from the previous slide   is very close to the world average, and  so, these data are fairly representative. And you can see that separation  anxiety disorder is the most common,   with social anxiety disorder and generalised  anxiety being somewhat less common,   but there are differences in patterns  across age. So, this column here shows   you children aged four to 11, and this column  is teenagers, aged 12 and 17. And you can see   that separation anxiety disorder is by far  the most common problem amongst children,   and then, actually decreases when they get  to adolescence. Whereas for social anxiety   disorder and generalised anxiety disorder it’s  the opposite pattern. That is that it’s less   common during childhood, and there’s a greater  likelihood of these disorders occurring – these   disorders increase in frequency when  these young people become teenagers. So, that gives us, then, some idea of the onset.  So, this is a slide I put together looking at the   emergence of anxiety disorders across the years,  and this is not a hard and fast rule by any means.   I make a very clear point that you can find any  anxiety disorder at any age in any child. So,   these anxiety disorders can begin at  any time, but in terms of frequency,   you’re more likely to see certain anxiety  disorders emerging at certain stages of   development. So, separation anxiety disorder  is typically the first, or the earliest onset,   and the most common onset tends to be  around toddlerhood or preschool age,   in the very early childhood years. And  then, you often find more specific phobias,   particularly the very concrete phobias, like fears  of animals, fears of the dark, fears of ghosts,   fears of heights. These will often start  to occur in early to middle childhood. Social anxiety disorder, although it can  occur at any age, tends to get a lot more   common in the late childhood/early  teenage years. Around about, sort of,   ten to 14 years of age is when social  anxiety disorder increases dramatically.   And generalised anxiety disorder is a little  bit more controversial. There’s mixed data,   some data showing that it doesn’t actually  begin until late adulthood, but there’s   also some strong data showing that it tends to  begin most commonly in the later teenage years. There’s some evidence that maybe there’s  two slightly different forms of generalised   anxiety disorder, one that tends to be more an  adolescent form that begins in late adolescence,   and the other one that tends to begin in middle  adulthood and is slightly different in terms of   its characteristics. And as I mentioned earlier,  of course, panic disorder and agoraphobia tend   to occur in – also in late teens, or really in –  the average age of onset is not ‘til the mid-20s. What are some of the risk factors for childhood  anxiety disorders? Well, there’s a number that   have been identified, firstly, heritability.  Putting it in very concrete terms, evidence   from twin studies suggest that around about 40%  of the variants, that is 40% of the variation in   symptoms of anxiety, can be directly attributed  to genetic input. So, genes are an important   component of the development of anxiety disorders,  but by far and away are not the full story. Inhibited tempretent – temperament, there’s some  strong evidence showing that young children from,   sort of, preschool, toddler, preschool, sort of,  age who are very shy, withdrawn and inhibited as   a temperamental characteristic, are more likely  to develop anxiety disorders in mid childhood,   and more likely to continue to have anxiety  disorders well into adolescence. So,   a shy and withdrawn, inhibited  temperament ear – in the early   years appears to be an indicator of  greater risk for anxiety down the track. Along with the heritability, of course, anxious  parents. We know – and in fact, it’s not just   anxious parents, but broadly, emotional parents.  So, parents who have anxiety and mood disorders   are more likely to have children with anxiety  disorders and so, having an anxious or a high   emotionality parent is one of the risk factors.  Other risk factors, there’s much less evidence   for. There’s a little bit of evidence that having  a parent who tends to have a style that’s very   overprotective, or where they tend to accommodate  or pre – or allow the child to avoid situations,   does increase the risk of the child having an  anxiety disorder. Evidence is mixed and messy,   as you would imagine, for that sort of a  factor, but there is consistent and reasonable   evidence showing that parent overprotection  increases risk for child anxiety disorder. Adverse life events are also important in child  anxiety, but they’re not specific to anxiety,   and there’s a wide range of mental disorders  for which life events are important. Early   adverse experiences, such as childhood  poverty or childhood abuse, sexual abuse,   physical abuse, increases the risk for  anxiety disorders, but it increases the   risk for other disorders even more so. So, it’s  not a strong or specific risk factor for anxiety,   but it is a risk, and social relationships,  having peers rejection – who reject the child,   being bullied or victimised early in life,  increases the risk of later anxiety disorders. And my final slide, putting all that together,  here’s just a bit of a theoretical model that   a colleague of mine, Jennie Hudson, and  I put together a number of years ago,   quite a number of years ago now. That  was really just a summary of some of   that – those risk factors that I just talked  about, to give an idea of how those things   might go together theoretically. So,  starting in the top right-hand corner,   you have a parent who’s highly anxious or highly  emotional, might be a better way to put it,   likely to provide their genes, and we know that  genetic factors account for 40% of the variant. What happens with the genetic factor, that is,  how they’re manifested, we theorise that perhaps   what happens is that that passes on an anxious  vulnerability. In other words, it doesn’t cause   kids directly to have an anxiety disorder, rather,  it increases their vulnerability to anxiety,   and one of the ways that we think it might work  is particularly through the avoidance. That is   that this anxious vulnerability appears to be  very strongly characterised by a fundamental   tendency for children to react to danger or  the threat, with avoidance. They run away at   the first chance they get, and those sort  of strategies, in turn, increase the risk   of developing an anxiety disorder, together with  a greater arousal and more emotional reactivity. In turn, that avoidance is supported by  parents in the anxious children, and in turn,   that parent support is also increased by the  fact that the parent themselves is anxious. And   that parent support of the avoidance goes back  to – provides a vicious cycle with the anxious   vulnerability and maintains that vulnerability.  There’s also some evidence that parents – anxious   parents will model their anxious responding for  their children. That is, they react in anxious   ways themselves and the child learns from that,  and in turn, that will increase vulnerability,   and we also know that the anxious vulnerability  increases the likelihood of stressful events   occurring, which in turn, increase the  likelihood of development of anxiety disorders. Thank you very much for listening.  I hope that I provided you some   interesting information about the nature  and characteristics of anxiety disorders   in young people. And if you would like to  listen to the next video in this series,   I’ll talk about the treatment of young  people with anxiety disorders. Thank you.