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 Article of Interest - Accommodations & Modifications

Evidenced Based Services and Anxiety

from SPIN Hawaii Online

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Evidence based services or interventions (EBS) are those that have been scientifically proven to have a positive effect in the treatment of a particular disorder. In our last issue we began sharing information from an important Hawaii report* about EBS for children and teens with mental health disorders that was released in December, 2002.

We continue in this issue to share the report's findings on what works in treating anxiety disorders in children and teens, so that families can make informed choices about intervention options. As you read these findings on effective practices keep in mind the following:

* no intervention or medication is 100% effective with all kids,
* only those studies that met scientific research standards (for example, randomized control and experimental groups) were reviewed,
* a number of promising practices in the field of children's mental health have not been studied thoroughly enough to receive an EBS rating, and
* if your child is receiving an intervention that is not listed in the report, but that seems to be giving real benefit, then it may be the best option available for him or her.

The important thing with any intervention is to have some way to measure its effectiveness.

What are Anxiety Disorders?

Anxiety is a natural part of every child's life. It normal for infants and toddlers to be distressed when they have to leave their parents, or for young children to be afraid of the dark. Teens worry about how they appear to others and about speaking up in class. Anxiety only becomes a mental health problem when it is persistent and severe enough to interfere with the child's normal functioning.

More children and teens suffer from anxiety disorders than any other mental health disorder. Of children age 9-17, roughly 13% will experience some form of anxiety disorder within the year. Here are some of the more common disorders:

Separation Anxiety Disorder involves fear of being away from parents or other caretakers. Often the child will be afraid of something bad happening to a parent and be reluctant to go to school, stay at friend's houses or sleep alone. Stomachaches and headaches are common.

Generalized Anxiety Disorder causes children to worry excessively about all sorts of things--upcoming events, grades, friends, family, being on time, even natural disasters. Other symptoms can include trembling, dizziness, stomach upsets, trouble sleeping and irritability.

Phobias are extreme fears of things or situations (such as spiders, heights, getting a shot, dogs, and flying). The level of fear is usually inappropriate to the situation and can lead the child to avoid common, everyday situations.

Social Phobia is the most common anxiety disorder in teens. It involves an ongoing fear of being embarrassed in social situations or in class. This anxiety can cause the teen to have trouble talking in class, taking tests or meeting new people.

Obsessive Compulsive Disorder causes frequent and uncontrollable thoughts or impulses (obsessions) about bad things happening. These thoughts lead the child to perform a ritual or routine (compulsion) like hand-washing or checking locks to relieve the anxiety caused by the obsession.

Post-Traumatic Stress Disorder can occur when children experience a physical or emotional trauma such as witnessing a disaster (like 9/11), being sexually or physically abused or being in a car accident. The child "re-lives" the trauma through nightmares or flashbacks, may be irritable, and have trouble eating, concentrating and sleeping.

What works in anxiety disorders?

THERAPY. In reviewing the most current studies, the Evidence Based Services Committee found the BEST SUPPORT for treating anxiety through Cognitive Behavior Therapy (CBT), exposure and modeling. Studies using CBT with parents included and Educational Support met the criteria for GOOD SUPPORT.

Cognitive Behavioral Therapy teaches the anxious child or teen skills to help them manage their fearful thoughts, so they can see that they do not always need to be afraid. Then, the child or teen participates in guided practice to get comfortable being around the things they are afraid of.

"In vivo" exposure, or real-life exposure, involves practicing approaching and confronting a feared situation or object.

Modeling involves demonstrating non-fearful behavior in a feared situation and showing the child or teen a more appropriate response for dealing with a feared object or event.

MEDICATION. The majority of the medication studies reviewed by the EBS Committee for use in treating anxiety disorders of childhood and adolescence did not have randomized controls, and so earned the rating of "C" which indicates minimal or no support. However, Selective serotonin reuptake inhibitors (SSRIs) were found to be effective and safe in the short term in treating Obsessive Compulsive Disorder (OCD). Common brand names include Zoloft, Paxil and Prozac.

Services that work:
For anxiety, phobias and avoidance behavior:
Cognitive Behavior Therapy (with or without parents), Exposure, Modeling and Educational Supports

Medications that work:
For obsessive compulsive disorder:
Selective serotonin reuptake inhibitors

Where do I go for help?

If you are concerned that your child may have an anxiety disorder you should check with your family physician or ask the school for help in evaluating whether school based behavioral health services are needed. Early intervention can prevent future difficulties, such as a loss of friendships, failure to reach social and academic promise and feelings of low self-esteem.

Thanks to Dr. Bruce Chorpita for his help with definitions for this article.

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