to be strongly effective. As with ADHD, the treat-
ments that are most likely to be effective include a
combination of treatments targeting not only the
child but also the family, school, and neighborhood.
The most effective treatments also take into consider-
ation the developmental status of the child and the
developmental trajectory of conduct problems for the
child, with the children most difficult to treat being
those who are farther along in the trajectory. Three
approaches to treatment that have at least some em-
pirical support are parent management training (fo-
cused on teaching parents new skills for managing
their child’s behavior); cognitive problem-solving
skills training (focused on changing children’s per-
ceptions and appraisals of interpersonal events); and
multisystemic treatment (focused on the context with-
in which the child functions, including family, school,
neighborhood, and the legal system).
Emotional or Internalizing Disorders
Some children develop depression and anxiety,
disorders that involve not only maladaptive thoughts
and emotions but also maladaptive behaviors. It is im-
portant to distinguish these disorders from common
depressed mood or childhood worries and fears.
Knowledge of normal development of emotions and
cognitions is helpful in making these distinctions.
Anxiety
Anxiety disorders in children are most likely to
fall into the DSM-IV diagnostic categories of general-
ized anxiety disorder, simple phobia, separation anx-
iety disorder, obsessive-compulsive disorder, or
posttraumatic stress disorder. Children diagnosed
with generalized anxiety disorder have a consistent
pattern, lasting six months or more, of uncontrollable
and excessive anxiety or worry, with the concerns cov-
ering a broad range of events or activities. In addition
to worry, symptoms include irritability, restlessness,
fatigue, difficulty in concentrating, muscle tension,
and sleep disturbances. Deborah Beidel found that
this disorder commonly begins at around age ten, is
persistent, frequently co-occurs with depression, and
is often accompanied by a number of physical symp-
toms such as sweating, suffering from chills, feeling
faint, and having a racing pulse.
In contrast to generalized anxiety disorder, chil-
dren with the other anxiety disorders have a much
more narrow focus of their concerns. Simple phobia
is typically focused on a specific situation or object.
With separation anxiety, children display excessive
fear and worry about becoming separated from their
primary attachment figures. This disorder is often ex-
pressed as school refusal or school phobia. Obsessive-
compulsive disorder consists of specific obsessions
(abnormal thoughts, images, or impulses) or compul-
sions (repetitive acts). Posttraumatic stress disorder
symptoms develop in reaction to having experienced
or witnessed a particularly harrowing event. Symp-
toms include sleep disturbances, irritability, attention
problems, exaggerated startle responses, and hyper-
vigilance.
For phobias and separation anxiety disorder, it is
particularly necessary to determine if a child’s fears
reflect typical concerns of the age group or are clini-
cally significant. Onset of a fear at a time that is differ-
ent from children’s age-typical fears is often an
important indication of clinical significance. Other
important indications of clinical significance include
fear reactions that are strong, persistent, and intense
and that interfere with school, family, or peer rela-
tionships. Similarly, it is essential to distinguish symp-
toms of obsessive-compulsive disorder from typical
childhood rituals and routines.
Although generalized anxiety disorder and spe-
cific phobias are among the most common disorders
in children, the other anxiety disorders are rare. Di-
agnosis of anxiety disorders is particularly difficult
because it is so dependent on self-reports from the
children. Children may not recognize that their fears
are excessive and typically do not complain about
them, although they will go out of their way to avoid
situations that evoke the anxiety.
The anxiety disorders are typically viewed as hav-
ing their origins in learning experiences. Children
may learn fears through imitation, instruction, or di-
rect reinforcement. Similarly, compulsive behavior
can develop from a chance occurrence when a child
felt positive reinforcement for engaging in a particu-
lar behavior because it was associated with reduced
anxiety.
Anxiety disorders that begin in childhood often
persist into adulthood. Thus it is particularly impor-
tant to treat them early. Behavioral or cognitive ther-
apies have been most successful. Treatment typically
involves a combination of graduated exposure to the
feared situation and teaching the child adaptive and
coping self-statements. The effectiveness and safety of
using medications was the subject of several studies at
the beginning of the twenty-first century; some early
findings showed promising results from the use of
antidepressants.Depression (Mood Disorders)
Depression is another relatively common disor-
der that often first appears in childhood or adoles-
cence. The DSM-IV includes the depression
diagnoses of major depression and dysthymia. To be
diagnosed with major depression, children must ex-
perience either depressed mood (or irritability) orMENTAL DISORDERS 263