Interventions for Childhood Anxiety Disorders – What Works Best from a Child's Perspective: A Qualitative Study

Abstract

Background
Anxiety spectrum disorders are the most prevalent psychopathology among children and adolescents. Qualitative research in childhood anxiety disorders can provide valuable insights regarding interventions. The objectives of this study were to examine the child's perspectives on the subjective experience of concerns, the impact of the symptoms on socioacademic functioning, and the process of recovery with interventions.

Methods
Children and adolescents aged 6–16 years, presenting with any subtype of anxiety spectrum disorder as per International Classification of Diseases and Related Health problems, 10th Revision (ICD-10) Diagnostic Criteria for Research, were included. Convenience sampling was used, and 30 children fulfilling inclusion and exclusion criteria were selected. An interview guide with simple questions to facilitate response was used, at the baseline and 12th week of follow-up, to generate a written narrative account of the experience of concerns, the impact of symptoms, and the treatment process. Children received treatment as usual, which included a workbook-based cognitive behavioral intervention.

Results
Content analysis was done using 30 baseline and 20 follow-up narratives. Clustering of themes were done. Themes related to the recovery process reflected perceived improvement in academic performance and competence, apart from the improvement in symptoms. There were more themes in favor of cognitive interventions.

Conclusion
Children's narratives highlight the importance of cognitive interventions for anxiety disorders.

Full text

© 2019 Indian Psychiatric Society - South Zonal Branch | Published by Wolters Kluwer - Medknow 235
Interventions for Childhood Anxiety
Disorders – What Works Best from a Child’s
Perspective: A Qualitative Study
Preeti Kandasamy, Satish Chandra Girimaji, Shekhar P. Seshadri, Shoba Srinath,
John Vijay Sagar Kommu
ABSTRACT
Background: Anxiety spectrum disorders are the most prevalent psychopathology among children and adolescents.
Qualitative research in childhood anxiety disorders can provide valuable insights regarding interventions. The objectives of
this study were to examine the child’s perspectives on the subjective experience of concerns, the impact of the symptoms
on socioacademic functioning, and the process of recovery with interventions. Methods: Children and adolescents aged
6–16 years, presenting with any subtype of anxiety spectrum disorder as per International Classification of Diseases and
Related Health problems, 10th Revision (ICD‑10) Diagnostic Criteria for Research, were included. Convenience sampling was
used, and 30 children fulfilling inclusion and exclusion criteria were selected. An interview guide with simple questions
to facilitate response was used, at the baseline and 12th week of follow‑up, to generate a written narrative account of the
experience of concerns, the impact of symptoms, and the treatment process. Children received treatment as usual, which
included a workbook‑based cognitive behavioral intervention. Results: Content analysis was done using 30 baseline and
20 follow‑up narratives. Clustering of themes were done. Themes related to the recovery process reflected perceived
improvement in academic performance and competence, apart from the improvement in symptoms. There were more
themes in favor of cognitive interventions. Conclusion: Children’s narratives highlight the importance of cognitive
interventions for anxiety disorders.
Key words: Anxiety disorder, child, interventions, qualitative study
Key messages: This qualitative study elicited children’s perspectives on illness experience and treatment impact in our
sociocultural setting. Children’s narratives highlighted the importance of cognitive interventions in childhood anxiety disorders.
Original Arcle
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DOI:
10.4103/IJPSYM.IJPSYM_509_18
Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
Address for correspondence: Preeti Kandasamy
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
E‑mail: preetikandasamy@gmail.com
Received: 13th December, 2018, Accepted: 23rd April, 2019
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How to cite this article: Kandasamy P, Girimaji SC, Seshadri SP, Srinath S,
Kommu JV. Interventions for childhood anxiety disorders – What works
best from a child’s perspective: A qualitative study. Indian J Psychol Med
2019;41:235‑9.
Anxiety disorders are considered the gateway disorders
for many of the adult psychiatric disorders.[1] Childhood
anxiety disorders, if untreated, can lead to chronic
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Kandasamy, et al.: Qualitative study on childhood anxiety disorder
236 Indian Journal of Psychological Medicine | Volume 41 | Issue 3 | May-June 2019
anxiety, depression, and substance abuse.[2] It is
therefore vital to effectively recognize and treat anxiety
disorders in childhood and adolescence.
An epidemiological study conducted in Bangalore
found a prevalence of 4% for anxiety disorders in
children age 4–16 years.[3] The anxiety disorders
among adolescents study had reported the prevalence
of anxiety disorder to be 14.4% (4.8% in boys and
9.6% in girls) as per Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV‑TR).[4] This study documented the
prevalence, pattern, comorbidities, and relationship
with depression, associated suicidal phenomenon, and
school phobia.[5] The prevalence of anxiety disorder
among children in the clinic population at a tertiary
care center was reported to be 20%.[6]
Interventional studies in the Indian context are limited,
and we mostly rely on research information from the
west. Qualitative research is scarce in child psychiatry,
but research has highlighted the need for qualitative
research to enhance our understanding of the children’s
experience and to provide them better care models. This
study aimed at examining the child’s perspectives on
the subjective experience of concerns, the impact of the
symptoms on the socioacademic functioning, and the
process of recovery with interventions.
METHODS
The study was conducted at a child and adolescent
psychiatry clinic at a tertiary care academic institute,
after obtaining the Institutional Ethics Committee
approval. Informed consent from parents and assent
from the child was obtained for participation in the study.
Children and adolescents with a diagnosis of separation
anxiety disorder of childhood, phobic anxiety disorder
of childhood, social anxiety disorder of childhood,
generalized anxiety disorder of childhood, social phobia,
specific phobia, panic disorder, obsessive‑compulsive
disorder, or posttraumatic stress disorder as per
International Classification of Diseases and Related
Health problems, 10th Revision (ICD‑10) Diagnostic
Criteria for Research were included. Screen for Child
Anxiety Related Emotional Disorders (SCARED) was
used for the initial screening, and Mini International
Neuropsychiatric Interview for children and adolescents
was used to establish the diagnosis. The first author
made the diagnosis, and it was concurred by the
second author. Convenience sampling was used, and 30
children fulfilling the inclusion and exclusion criteria
participated in the study.
A workbook for cognitive‑behavioral therapy (CBT) was
used to standardize the interventions received by all
the study participants in addition to the standard care.
The components of the workbook were reviewed and
approved by all authors and were delivered by the first
author. It included training in labeling and monitoring
anxiety, mind–body relationship, relaxation strategies,
thought diary, problem‑solving, coping strategies,
challenging negative thoughts, and teaching a friend
overcome anxiety. This was delivered over four to eight
sessions as per the needs of the child.
The following interview guide was used to generate
a response. Children and adolescents gave a written
narrative account at baseline and at 12 weeks of
follow‑up.
At baseline:
1. What is the nature of your concerns (problems)?
What is your current experience of these concerns
and how significant are they?
2. What impact do these symptoms have on you and
the activities you perform at home, school, and other
situations? How do they affect your well‑being?
How do they affect your efficacy (competence)?
3. What do you feel is the cause/reason for these
problems (symptoms)?
4. How hopeful do you feel about improvement/
recovery? In what way you want the treating team
to assist you in the process of recovery?
At follow‑up:
1. What is the nature of your current concerns
(problems)? What change have you experienced in
the past 3 months?
2. What impact do these symptoms have on you and
the activities you perform at home, school, and other
situations? How do they affect your well‑being?
How do they affect your efficacy (competence)?
3. What is your current thinking about the cause/
reason for these problems (symptoms)?
4. How hopeful do you feel now about improvement/
recovery? In what way did the treating team assist
you? What have you learned and mastered in the
past few months? What do you feel helped you?
RESULTS
The qualitative analysis was done using 30 written
narratives at baseline and 20 written narratives
at follow‑up. There were 16 boys and 14 girls.
Children who had completed at least four sessions of
CBT (n = 20) gave the follow‑up narrative at the end
of 12 weeks. There were 15 narratives by children age
6–12 years and 15 by adolescents in the age range of
13–16 years. There was no significant difference in
gender or age group among those who provided the
follow‑up narratives.
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Kandasamy, et al.: Qualitative study on childhood anxiety disorder
Indian Journal of Psychological Medicine | Volume 41 | Issue 3 | May-June 2019 237
The most common diagnosis was social anxiety
disorder (n = 19), followed by generalized anxiety
disorder (n = 11), obsessive‑compulsive disorder (n = 7),
and separation anxiety disorder (n = 4). Around
56% (n = 16) had two or more anxiety disorders.
Most children were school‑going and able to give a written
narrative account. A few younger children (n = 3)
required assistance in understanding the questions and
writing down their thoughts. Adolescents’ narratives
were more detailed than those by younger children.
The illness experience and illness impact were analyzed
using the baseline narratives; and the treatment impact
and the subjective experience of change using the
follow‑up narratives.
Content analysis was done manually by examining
core statements made in response to the interview
guide. Thematic analysis was done, commonalities
and differences were examined, and repetitive themes
were identified. A few predetermined themes were used
during the analysis to assess the change process with
the intervention (e.g., internalization of interventions).
Data interpretation was examined independently by the
third author to establish the validity of the findings.
Repetitive themes emerged in the areas of achievement,
interpersonal difficulties, self‑esteem, and self‑efficacy.
Impact on academic and nonacademic achievement,
as well as interpersonal difficulties in family, peer, and
social setting, emerged during analysis [Table 1]. A few
examples are provided below:
1. Illness experience:
a. Terms used to describe anxious affect
For example, anxious (n = 5) > scared/tensed/shy (n = 4)
> nervous/afraid (n = 2)
b. The most common responses for the question on the
perceived cause of the illness were internal (n = 12)
or external (n = 10), and a few had a disease
model (n = 5). External causes included life events.
“The reason for this problem is tension and worry.”
“Stress about studies. I always think more about the
future.”
2. Illness impact:
A majority of responses on illness impact reflected the
impact on performance in academic activities (n = 18),
play (n = 16), and other age‑appropriate activities (n = 5).
Responses on the impact on relationships showed
perceived impairment in peer relationship (n = 16),
family relationship (n = 6), and interaction with school
authorities (n = 2).
For example, “Cannot complete the day.”
“I never go out to play or for anything else.”
3. Treatment impact:
For the interview guide on treatment impact, there were
more responses to nonpharmacological intervention
as against pharmacological interventions. Cognitive
components (n = 14) such as problem‑solving,
positive self‑talk, challenging negative thoughts, and
process‑based approach were more common among the
responses than behavioral interventions (n = 6) such
as relaxation strategies, graded exposure, and exposure
and response prevention. A few children (n = 4) also
reported parental interventions such as psychoeducation
and addressing parental anxiety as having helped them.
Children’s responses to treatment impact reflected
their perceived improvement in academic performance
and competence, apart from the improvement in the
symptoms.
For example, “Return to school.”
“Giving exams without fear.”
“Performing better.”
Two samples are given below to enable comparison
of the child’s subjective experience at baseline and at
follow‑up, which highlight the impact of the treatment.
Sample 1:
Baseline:
“I’m afraid, and I feel anxious for silly things. Whenever
I am pointed out to answer or something else, my whole
body starts shivering, and I sweat a lot. I thought of
myself a waste‑bin.”
“These symptoms made me feel I am good for nothing.
I can’t face any problem and this has been my behavior
throughout my life. I’m going to be someone who can’t
face things.”
Table 1: Themes for illness impact
Illness impact Categories No. of responses
Achievement Academic 18
Play and extracurricular 9
Interpersonal
relationship
Peer 16
Family 6
Others 2
Self Self‑esteem 6
Cognitive development 4
Social development 1
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Kandasamy, et al.: Qualitative study on childhood anxiety disorder
238 Indian Journal of Psychological Medicine | Volume 41 | Issue 3 | May-June 2019
“All this problem is because I want myself to be the
best person in the world and I started stressing myself
for that.”
Follow‑up:
“Now I’m able to understand my problems and why I’m
suffering like this. I’m able to overcome things and to
suggest myself solutions for these problems. Before, I used
to depend on parents now I can do it myself. Whenever
the symptoms occur, I’m able to manage them.”
“Now also I want myself to be the best, but I don’t stress
myself like before. The therapy sessions helped me to
get back to my studies and my dreams. They made me
think and act and changed me a lot. I don’t worry about
the results. I can feel the change in me, and the people
around me can also see the change in me.”
Sample 2:
Baseline:
“My problems are somehow related to people around
me. Right now, I’m scared—very scared of my school
and exams. I don’t want to go to school. These problems
are making me feel irritated, angry, frustrated and
depressed, which in turn ruins my relationship with
other people. I’m getting panic attacks. My fear of
exams is leading to this.”
Follow‑up:
“My problems are about relationship issue, indecision,
low self‑confidence, and self ‑esteem. These make me
panicky, irritating, and angry too. Depression is also
there (but I can’t realize it). I become nervous; as a
result, I’m not able to do anything properly. I start
daydreaming, and I’ve mood swings.”
“I’ve grown up a lot in this past one and a half months.
I’m more sure of myself now and have started realizing
my mistakes. I now have more faith in myself. I’ve
learned to relax and not to take life so seriously. I’ve
learned to let go. I’ve learned to praise myself, and my
mood is more balanced … I think, the one thing that
helped me besides medicines is talks with my doctor
and parents.”
DISCUSSION
This qualitative study was an attempt to collect
the opinions children with anxiety disorders have
regarding the illness experience and treatment process.
It elicited the impact the symptoms had on the
child’s achievement, interpersonal functioning, and
self‑esteem, the depth of which other clinical measures
and rating scales often fail to capture.
Follow‑up narratives reflected a perceived improvement
in self‑efficacy and competence with the interventions;
themes reflected internalization of cognitive
interventions.
The study answers a few critical questions that a
clinician often encounters while handling young
children with anxiety: To what extent the improvement
made is part of the natural course of development
or the effect of treatment? Do cognitive behavioral
interventions help the children in our cultural setting?
If so, which component? The study adds clinical value
and relevance to the already existing quantitative data.
It was interesting to note that only a few children
perceived that the medications helped them (n = 4).
Most responses of the children (n = 30) mentioned
the cognitive, behavioral, and other psychosocial
interventions as having helped them. Although there is
a larger focus on behavioral interventions for childhood
anxiety disorders such as relaxation strategies and
graded exposure, it was interesting to note that many
responses reflected that cognitive interventions helped
them most.
The use of workbook‑based CBT seems viable in
our sociocultural setting and feasible for delivery
to school‑going children. However, challenges were
encountered in retaining the children for multiple
sessions. Attrition was high: one‑third of them had
dropped out by the 12th week of follow‑up.
There has been a move toward research with children
engaging them as active participants.[7] This study
has reiterated the fact that systematic and rigorous
qualitative research has much to offer child and
adolescent psychiatry.[8] Studies with more rigorous
methodology are required.
Limitation
The sample was heterogeneous and included children
with different anxiety disorders, with a wider age range
of 6–16 years. This might explain the differences in the
reported experiences.
CONCLUSION
This qualitative study was an attempt to elicit children’s
perspective on illness experience and treatment process.
Children’s narratives highlighted the importance of
cognitive interventions. Further studies examining
the efficacy of workbook‑based cognitive‑behavioral
interventions are needed to address the current lack
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Kandasamy, et al.: Qualitative study on childhood anxiety disorder
Indian Journal of Psychological Medicine | Volume 41 | Issue 3 | May-June 2019 239
of trained professionals to deliver cognitive‑behavioral
interventions.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
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