ANXIETY DISORDER PowerPoint Presentation

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Anxiety Disorders, OCD, School Refusal Sucheta Connolly M.D. Pediatric Stress & Anxiety Disorders Clinic University of Illinois at Chicago

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Normal Fears and Worries Infants: fear of loud noises, strangers Toddlers: fear of the dark, monsters, separation from parents School-age: physical injury, storms, school Teenagers: social evaluation and school performance

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Common Stressors Divorce Family move or friend moves away Loss of pet Break up with girlfriend/boyfriend Poor performance at school/test Death of relative Transition to middle school/high school

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Signs and Symptoms of Stress and Anxiety in Youth Recurrent fears and worries Difficulty falling asleep or nightmares Hard to relax Difficulty separating from parents Scared about going to school Irritability, crying, tantrums Uncomfortable in social situations at school, restaurants, parties

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Anxiety Disorders in Children and Adolescents Very common: 8-10% of youth have at least one anxiety disorder Runs in families (Genetics and modeling) Co-occur with ADHD in children, and depression and substance abuse in teens Can persist into adulthood Treatments are available and effective: Cognitive-behavioral therapy and medication Early identification and treatment can reduce severity and impairment in social and academic functioning

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Separation Anxiety Disorder Excessive fear and distress when separated from parents/primary caregivers or home Worry about parents’ health and safety Difficulty sleeping without parents Difficulty alone in another part of the house Complain of stomachaches and headaches May refuse to go to school or playdates

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Generalized Anxiety Disorder Excessive, chronic worry related to school, making friends, health and safety of self and family, future events, local and world events Also has at least one of these symptoms: motor/muscle tension, fatigue, difficulty sleeping, irritability, poor concentration Often perfectionists Anxiety may be significant, but not apparent to others Physical complaints are common

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Social Phobia (Social Anxiety Disorder) Excessive fear or discomfort in social or performance situations Extreme fear of negative evaluation by others Worry about doing something embarrassing in settings such as classrooms, restaurants, sports, musical or speech performance Difficulty participating in class, working in groups, attending gym, using public rest rooms, eating in front of others, starting conversations, making new friends, talking on the phone, having picture taken

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Selective Mutism Unable to speak in certain situations (school) despite able to speak in other settings (home) Difficulty speaking, laughing, reading aloud, singing aloud in front of people outside the family or their “safe zone” Speech/language development normal, but may have some speech/language difficulties Parents or siblings often speak for the child Often have symptoms of social phobia as well

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Specific Phobia Excessive fear of a particular object or situation May avoid the feared object or situation If a fear is severe enough to impair a child’s functioning, then it is a phobia Common phobias: animals/insects, heights, storms, water, darkness, blood, shots, traveling by car/bus/plane, elevators, loud noises, costumed characters, doctor or dentists, vomiting, choking, catching a disease

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Panic Disorder Recurrent panic attacks or intense fear: racing heart, sweating, shaking, difficulty breathing, nausea, dizziness, chills/flushes, numbness/tingling, fear of dying/going crazy Eventually child feels frightened “out of the blue” or for no reason at all Can lead to avoidance of situations due to fears of having a panic attack

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Obsessive Compulsive Disorder Obsessions: Scary, bad, unwanted or upsetting thoughts, impulses, or pictures that keep coming back over and over Examples of obsessions: Aggressive obsessions, contamination, doubting, nonsensical thoughts, hoarding/saving, religious, symmetry/exactness, violent thoughts/images, thoughts about sex, thoughts of death/dying Child tries to ignore or suppress the thoughts, impulses, or images

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Obsessive Compulsive Disorder Compulsions: repetitive behaviors or mental acts (praying, counting, repeating words/numbers silently) that the child feels compelled to do in order to stop discomfort/anxiety of obsessions Examples: Cleaning/washing, checking, counting, hoarding/collecting, repeating words/numbers silently, ordering/arranging, praying, seek reassurance, touching/tapping, “tell on yourself”, “just right” Persistent obsessions, compulsions, or both that occupy more than 1 hour each day Repetitive and difficult to control

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Postulated Infectious/Autoimmune Etiology Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep. = PANDAS Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders = PITANDs

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Infection (group A beta-hemolytic strep.) Immune Response (antibodies produced) Reversible (?) Lesion of Basal Ganglia OCD and/or tics PITANDs (PANDAS) Pathophysiology

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Treatment Planning for Childhood Anxiety Disorders

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Treatment Planning Age, severity, impairment, and comorbidity Mild severity: Consider CBT first Mod-severe: Medications considered for acute relief of anxiety, partial response from other treatment, comorbid disorders that may benefit from meds and multimodal approach Severe: Combination intensive treatments with CBT and medications may be necessary Older youth, depression, and social withdrawal often need intensive treatment Involve child and family in treatment planning

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Treatment Planning Continued If Parental Anxiety Disorders Present: Teach parents anxiety reduction skills Consider if independent treatment of parental anxiety disorders needed (meds, therapy) Consider additional parental involvement with younger child Older youth - depression, social withdrawal, substance abuse often need intensive focus

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19 Child-Adolescent Anxiety Multimodal Study (CAMS)(Walkup, et al.: N Eng J Med, 2008) 488 children (7-17y):SAD, GAD, Social Phobia 14 sessions of CBT, sertraline to 200mg/day, combination CBT and sert, or 12 weeks of placebo. Very much or much improved on CGI-Improvement scale: 81% combination, 60% CBT, 55% sertraline, 24% placebo Both CBT and sertraline reduced severity of anxiety in children with anxiety disorders, combination had superior response rate

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20 CAMS Study Moderate to severe anxiety disorders No increased frequency of physical, psychiatric, or harm-related adverse events in sertraline vs. placebo groups Suicidal or homicidal ideation was uncommon, no child attempted suicide Youth with ADHD were included. Youth with depression or PDD were excluded Combination therapy offers best chance for positive outcome: consider family preference, cost, treatment availability. Placebo for sertraline only group, not for sertraline plus CBT group.

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CBT and Beyond Standard CBT Social skills training Assertiveness skills Self-esteem Working with parents and schools

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think feel CBT Model of Anxiety:Anxiety’s Three Components Cognitive: Physiological: Behavioral: do

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Social Phobia Fears of being the focus of attention and embarrassing self Increased heart rate, shaking, sweating, hyperventilation, dizziness Avoidance of feared social situations, pseudomaturity, school refusal think feel do

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24 CBT Principles for Anxiety (Albano & Kendall) Identifying & monitoring anxiety symptoms Psychoeducation (about anxiety and CBT) Somatic management skills training (self-monitor anxiety and learn muscle relaxation, diaphragmatic breathing,imagery) Cognitive restructuring (challenge negative thoughts and expectations; positive self-talk; Practice Problem Solving Skills Exposure methods (imaginal and live exposures with gradual desensitization) Relapse prevention and booster sessions

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Treatment of Anxiety Disorders in Children and Adolescents Psychoeducation with the child and parents about the illness and principles of CBT Parent training to establish daily structure, expectations, positive reinforcement, monitoring of symptoms and progress Involve parents in treatment, especially for children and when parental anxiety present Consider independent treatment of anxiety disorders in parents Coordinate treatment with school

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CBT for Anxiety Disorders in Children and Adolescents Consider age and developmental stage of child For younger children using positive reinforcement chart and frequent rewards for efforts is very important. Exposures increase anxiety and children need motivation to try. For younger children use of pictures, cartoons, puppets, and toys to supplement standard CBT is helpful.

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Establish Target Symptoms Learn to identify feelings in self & others (feelings barometer) Establish level of distress (feelings thermometer) Develop Ladder of stimuli or triggers (situations, objects, cues, sensations) within primary diagnosis

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Somatic Management Skills Training Diaphragmatic breathing Muscle relaxation Imagery

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Cognitive Restructuring Challenge Negative Thoughts Challenge Negative Expectations Positive Self-Talk

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Cognitive Distortions Youth with anxiety disorders: Assume bad things will happen Biased attention to threatening words and criticism Interpret ambiguous situations as threatening More negative self-talk Underestimate their strengths Assume they cannot handle stressful situations Catastrophic thinking: Assume the worst

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Cognitive Restructuring: Goals Identify negative thoughts that predict bad things will happen- thinking traps Evaluate negative thoughts to determine if they make sense Use realistic positive self-talk to argue with negative thoughts and boss them back. Replace thinking traps with coping thoughts

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Cognitive Restructuring Use similar strategies to come up with alternatives to negative thoughts or misperceptions that result in angry feelings Boss back aggressive urges Practice alternatives to assuming someone will violate you, hurt you, criticize you, misunderstand you

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EXPOSURES Imaginal Exposures Role-plays Live Exposures

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Exposures Graded so child can experience success and build confidence (not flooding) Explain that discomfort is part of exposure Begin with relaxation exercise to start with anxiety at low level Review coping strategies Establish reward system Move from easiest to most challenging items on Fear Ladder Therapist should avoid too much reassurance during exposure

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Graded Imaginal Exposure Child imagines item or situation from Fear Ladder/Hierarchy in detail Begin with easy items to more challenging Child notes intensity on Fear Thermometer Bring anxiety to 2 or below before next item Ask: Did anything terrible happen? Praise often. Reward for efforts & successes Incorporate relaxation and self-talk learned to reduce anxiety Adjust frequency, intensity of sessions based on success

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Other Applications for Exposures Imaginal exposure and role-plays can be used for a range of behaviors This may allow child to identify feelings and thoughts that pop out in certain situations that make them angry, sad, scared Gives opportunity to practice new coping strategies and behaviors Be sure to praise for just trying exposures (imaginary or real)

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Treatment for Social Phobia and Panic Disorder Successful treatment of Social Phobia and Selective Mutism requires CBT discussed and additional Social Skills Training Treatment of Panic Disorder Often requires medications (SSRI’s, other antidepressants first-line) CBT for treatment of Panic disorder Interoceptive exposure. Relaxation training, experiencing physical symptoms in sessions, and overcoming sense of panic/doom. Decrease avoidance & increase control.

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Treatment for Selective Mutism Most children with SM have Social phobia Often need CBT and social skills training Severity often warrants medication (SSRIs) Management team with parents and teacher monitoring child’s communication Positive reinforcement for attempts on graded exposure ladder Steps to speaking outside “comfort zone”: Relaxed nonverbal communication, mouthing, speaking to parent, whispering to peers Discourage others from speaking for the child Videotaped modeling

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CBT Modifications for SM Team approach with school involved regularly Conversational visits Verbal intermediary (parent, friend, doll, toy puppet, recording device) that makes more comfortable in trying to speak/communicate. Does not speak for child. Positive reinforcement frequently Reinforce for nonverbal as well as verbal responses SM child can enlist strong negative response in adults (labeled as “refusing to talk”) Parents and siblings need to resist desire to speak for child

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School Refusal Can be variety of fears (separation, social anxiety, test anxiety) Worry, tension, increased heart rate, shaking, sweating Frequent absence, tardiness, tears, tantrums, somatic complaints, visits to school nurse think feel do

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School Refusal/School Phobia This is a behavior cluster, not a diagnosis Need to consider anxiety disorders and depression Consider SAD, GAD, Social phobia Need to rule out learning disability that can lead to frustrations, poor performance, low self-esteem. Increased risk for anxiety and depression. Dyslexia in young children. More common during transitions to a new school (pre-school, KG, middle school, high school) Assist parents to reduce secondary gains

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Interventions for School Refusal Rule out LD and language impairments If depression and anxiety present, CBT and meds often needed Assist parents and school staff to maintain patient in school. Avoid home-bound school Use library or other area to calm or complete work part of day, build up in class time Graded exposures to school situations Active ignoring of unreasonable somatic complaints and reward regular attendance Use relaxation and coping strategies to reduce anxiety at school. Coaches at school too.

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School Refusal: Fear/Exp Ladder Be careful not to start exposures close to vacations or holidays Initially work on preparing for going to school (depending on severity of fears) with live and imaginal exposures (driving past school, walking on school grounds, entering school) Increasing time at school, not necessarily in classroom Start with most comfortable setting/activity in classroom Work up to part of day and eventually full day Set up rewards for each step

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Treatment of Youth with OCD Multimodal Approach

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Treatment of Youth with OCD Cognitive behavioral therapy (CBT) in conjunction with medications (SSRI’s) Exposure and Response Prevention (E/RP) Develop fear hierarchy, expose to phobic stimuli and repress rituals or avoidance Family therapy can help decrease the parents’ involvement in the child’s rituals and reinforcing behavior-based interventions Selective serotonin reuptake inhibitors (SSRI’s) and Clomipramine (TCA and SSRI) are effective

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Boy with OCD 11 year boy with OCD Intrusive sexual thoughts/fears. Doubting: Reassurance seeking “Is this right? Am I OK?” Fears of upsetting and harming others. Underwear and pants have to fit “just right”. Mother has to take in all waists. Nothing can be loose fitting Perfectionism: Erasing, rewriting drawings, work to make it “right”. Takes lots of time. Cannot be rushed to complete things. Fears of upsetting God and others: apologizing, “I’m sorry”, Sign of the cross

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How I Ran OCD Off My Land (J. March MD, MPH: March Manual) Psychoeducation with OCD as medical illness and engage child and family in treatment Define OCD as the problem: nasty nickname with plans to “boss back” OCD with therapist Story about OCD in child’s life: over time authors OCD out of his/her life Map child’s OCD: obsessions, compulsions, triggers, avoidance behaviors, consequences Anxiety management training Exposure and response prevention (E/RP) using transition zone where some success in resisting OCD (diagram)

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CBT for OCD: Adaptations for Young Child OCD Storybook (with farm animals and OC Flea) Positive reinforcement program Readjust hierarchy to achieve success with little steps in exposures if needed. For young children can do imaginal exposures using puppets, toys, cartoons to practicing “bossing back” OCD Can adopt characteristics from superheroes that help child to defeat OCD Watch OCD shrink in size, make this concrete for young children in various ways OCD monster and worry monster are similar

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OCD Exposure/Fear Ladder Holding doorknob (exposure) and not washing hands (response prevention) Moving items around in room (E) and not reorganizing before leaving the house (RP) Complete homework assignment without rechecking several times Wear socks to school that are not perfectly matching Arrive late to school or event and still participate Imaginal exposures for obsessions not associated with compulsions

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Social Skills:Meeting and Greeting New People Having a conversation: taking turns asking, telling, saying something and listening Role-play situations with child or teenager Practice with a friend and new children Coordinate with school staff (lunch group) Involve parents in sessions in younger child

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Social Skills: Nonverbal Communication Importance of nonverbal communication and improving conversation skills Personal space Eye contact Speaking voice (volume) Involve parents in sessions for younger child

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Assertiveness Training Many anxious children work hard to always please others and avoid conflicts May fear something bad will happen if they upset others or just discomfort More likely to be bullied Child works on identifying own needs and negotiating these with children and adults Review assertiveness strategies, role-play in session, then carry out exposures Can use toys, puppets with young children to practice. Involve parents in sessions. Use relaxation, coping strategies and fear ratings during role-play

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Assertiveness Training: Example 6 y.o. girl with GAD, SAD, Turner’s & small stature. Often picked up by other children and girls fight over her not allowing her to play with other peers. Sometimes children hold her down. Led to school phobia. She fears other children will be punished if she tells. Practiced using loud voice, mean face and posture in session. Role-play with peers who are pushy and demand her to listen. Practiced turning on “drama” when child annoying her and will not accept no to get teacher’s attention Coordinated plan with school regarding practicing assertiveness and monitoring of bullying by teacher in classroom and especially at recess. Patient has benefited greatly from CBT, low dose SSRI.

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Working with Parents and Schools Active Ignoring Rewards Involving Parents in CBT with child Working with Schools Family treatment

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Working with Parents and Teachers: Active Ignoring Active reinforcement of positive behaviors Active ignoring of unwanted behavior to extinguish (complaining, reassurance-seeking, crying, whining, somatic complaints) Role-play with parents, discuss with teachers Temporary increase in problem behavior, does not mean they should give in Reduces children depending on adults rather than trying new coping skills

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Working with Parents and Teachers: Rewards Child chooses meaningful rewards Small, inexpensive, or preferred activity Reinforcement after desired behavior (trying not just successes) Short list of desired behaviors (fear ladder) Substitute new behaviors as mastered Timely, consistent rewarding Coordinate reward system between home & school Post in visible location at home; teacher keeps in desk at school Child learns self-praise over time

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Involving Parents in Treatment Parents with anxiety disorders can benefit from anxiety management skills/treatment and can improve effectiveness of CBT in child Parents may be overprotective, controlling, or facilitate avoidant responses Parents included in child’s treatment as “coaches” to assist child in coping with current and future anxiety issues

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Parent Involvement Learn how to handle child’s anxiety Learn graduated exposure and how to use it Modify view of child as vulnerable and in need of protection or control See child as resilient and capable of coping Help parent to feel knowledgeable and skilled enough to help the child cope with future challenges Involve all relevant caregivers to increase consistency of response to anxiety

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Parent (Teacher) Involvement Parents (teachers) can model calmness and problem-solving approaches Find middle ground: encourage the child to approach feared situations and give child control over pace that is tolerable Give prompts, but resist need to “rescue” Focus on small, positive steps, build courage, competence, and autonomy for child

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School Interventions for Anxiety School personnel who child can meet with regularly and be available to help child calm Discourage leaving school (fever or vomiting) Encourage self-monitoring with Feelings Thermometer Coping bag available if needed Reinforce attempts to use relaxation/coping skills as well as successful coping Desensitization program with graded exposure Regular contact & coordination with parents

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School Interventions for Students with Anxiety Modified assignments Comprehension checks Identify adult at school outside classroom who can meet with child and engage in problem-solving or anxiety management strategies School staff prompt child to use coping strategies prior to school triggers (tests, recess, starting assignment) Testing in private, quiet place to reduce anxiety Educate teacher about child’s anxiety and suggest strategies to facilitate child’s coping (reframe) Children with anxiety disorders might qualify for a Section 504 plan or special education if significant impact on school functioning (handout)

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Family Interventions Parental emotional overinvolvement Parental criticism and control Family communication Impact of child anxiety on parent behavior Integrative models (Dadds & Roth, 2001) Interaction between attachment and parent-child learning process, behavioral and temperamental characteristics of child and parent Consider impact on siblings

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Family Interventions Can… Address risk factors such as parental anxiety, insecure attachment, parenting styles. Improve parent-child relationships Strengthen family problem solving Strengthen family communication skills Foster parenting skills that encourage healthy coping and autonomy in anxious child

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Medication Treatment for Childhood Anxiety Disorders

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Medications for Childhood Anxiety Disorders SSRIs only medications well-supported by placebo-controlled studies: SAD, GAD, SoPh Consider comorbid disorders Consider family history of medication tx Try several SSRI’s before alternative meds No clear guidelines when more than one medication needed to manage anxiety Initiate one medication at a time Start low and go slow, monitor side effects closely

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Serotonin Reuptake Inhibitors Randomized placebo-cont trials of SSRI’s short-term efficacy & safety for anxiety dx Fluvoxamine - Social phobia, SAD, GAD (RUPP, 2001) Fluoxetine - GAD, Social phobia, SM (Birmaher et al, 2003; Black and Uhde, 1994) Sertraline - GAD (Rynn et al, 2002) Paxil - Social phobia (Wagner et al, 2004) Panic disorder - small open label and chart review with SSRIs showed improvement

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SSRI’s for Anxiety Disorders Side effects: stomachache, increased activity level, insomnia, agitation/disinhibition at higher doses Less often diarrhea, headaches, tics, cramps/twitching, hypomania, sexual side effects. Ask patient to wear sunscreen. Start at a low dose and increase slowly based on treatment response and side effects Can increase dose one month Can take several weeks to 2 months to see full effect (may see initial result quickly)

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SSRI’s for Anxiety Disorders Discuss black-box warning with family Choice of SSRI: side effects, duration of action, pt compliance, positive response in relative Assess somatic symptoms prior to initiating May consider mediation free trial after stability for 1 year, during low-stress period, with monitoring for relapse (Pine, 2002)

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SSRIs: Side Effects by Age Activation and vomiting more in children versus adolescents (Safer & Zito 2006) Children (especially females) with higher exposure to Fluvoxamine at similar doses Behavioral disinhibition noted in some SM med studies with younger children (Carlson et al 1999; Sharkey & McNicholas 2006)

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SSRIs in Young Children Start very low in young children and go slow to reduce side effects and increase tolerance to initial and temporary side effects Fluoxetine liquid 20mg/5ml can start at 0.5-2.0 mg/day Sertraline liquid 20mg/1ml can start at 2.5-5mg/day Monitor for activation, behavioral disinhibition along with other side effects

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SSRIs for Selective Mutism 12 week placebo- controlled study for Fluoxetine mean dose of 0.6mg/kg (Black and Uhde, 1994) 6 children, ages 6-14, with SM and Social Phobia Improved significantly on parent and teacher rating relative to placebo but still with SM symptoms (with minimal side effects) Open trial of 21 children ages 5 to 14 with SM supports Fluoxetine in graduated doses. 76% improved in anxiety and speech, inversely correlated with age (Dummit et al., 1997) Sertraline in 5 children with SM with low side effects, general benefits (Carlson et al., 1999) Longer trials with more individual dosing needed

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Other Antidepressants Tricyclic antidepressants (SAD, Social phobia) Conflicting results exc Clomipramine for OCD Clomipramine (TCA & non-selective SRI) Can augment at low doses with SSRI. Requires cardiac monitoring, EKG, blood levels. Side effects can be significant: sedation, dizziness. OCD, ADHD, tics. Other Antidepressants (GAD, Social phobia) Venlafaxine ( 2 placebo-cont studies w/XR: Rynn et al 2007; Tourian et al 2004 ) Noradrenergic and SSRI. Second line treatment as SSRI alternative or augment. Panic, ADHD.

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Other Medications for Anxiety Buspirone (GAD) No published controlled studies. Adverse side effects: lightheadedness, headache, dyspepsia. Higher peak plasma levels in children vs adolescents. May be tolerated at 5-30mg in teens and 5-7.5mg in children, twice daily May be an alternative to SSRIs for GAD in youth. Controlled studies needed. May augment SSRIs.

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Other Medications for Anxiety Benzodiazepines Clonazepam: benzo most used in youth Small controlled studies did not show efficacy Short-term use for school refusal, SAD, Panic disorder to supplement SSRI or allow acute participation in CBT(exposure) Risks of dependence long-term, half-life Contraindication in teens w/ substance abuse Side effects: sedation, disinhibition, cognitive impairment, difficulty with discontinuation Long-term use in GAD or severe chronic anxiety if other alternatives exhausted

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Other Medications for Anxiety Guanfacine or Clonidine No controlled studies for anxiety disorders Consider w/ SSRI when anxiety w/ significant autonomic arousal and/or restlessness Baseline EKG, BP and pulse monitoring Severe rebound hypertension with abrupt discontinuation Tourette’s, ADHD, Trichotillomania, other impulse-control disorders, Bipolar, PTSD B-Blockers Consider for focused performance anxiety (No trials in youth)

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Medications for Comorbidity Depression: Impairment, SSRI, monitor suicidal risk, CBT (Fluoxetine recommended) ADHD: First choice stimulants and beh tx. If stimulants exacerbate insomnia or anxiety, Atamoxetine second line, also Buproprion and Venlafaxine. Guanfacine or clonidine (get EKG) for hyperactivity/ impulsivity and sleep struggles. Alcohol abuse: Caution against benzos Bipolar disorder: SSRIs may exacerbate, but can be introduced at low doses once stable

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Treatment of PTSD: Medications Treat significant depression and anxiety SSRI’s (Antidepressants) For anxiety, depression, core symptoms Guanfacine or Clonidine For hyperarousal, impulsivity, startle Antipsychotics (such as Risperidone) For dissociation, brief psychosis, severe aggression (monitor AIMS or DISCUS, glucose, weight) Meds can reduce severity of symptoms so child can engage in therapy and exposures

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Medications for Comorbid Autism Spectrum Disorders Consider SSRI’s when obsessive features, perseveration, rituals, anxiety, depression, irritability prominent Guanfacine or Clonidine may assist with impulsivity, explosiveness, restlessness Other meds such as antipsychotics and mood stabilizers may be used for aggression and severe symptoms

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CBT Anxiety Therapy Manuals Coping Cat (Phillip Kendall, 1990, 2000) and CAT (for adolescents) How I Ran OCD Off My Land (John March) Meeky Mouse Therapy Manual: CBT Program for Selective Mutism (D. Fung, A. Kenny & S. Mendlowitz, in press) Social Effectiveness Training for Children (SET-C: Beidel & Morris) - for Social Phobia Modular Cognitive Behavioral Therapy for Child and Adolescent Anxiety Disorders (Bruce Chorpita, 2001)

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RESOURCES National Child Traumatic Stress Network www.musc.edu/tfcbt; www.nctsnet.org American Academy of Child & Adolescent Psychiatry (AACAP) www.aacap.org Anxiety Disorders Association of America (ADAA) www.adaa.org SM Group- Child Anxiety Network www.selectivemutism.org Association for Behavioral and Cognitive Therapies www.abct.org Obsessive Compulsive Foundation www.ocfoundation.org