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Anxiety disorders are a category of mental disorders characterized by feelings of anxiety and fear, where anxiety is a worry about future events and fear is a reaction to current events. These feelings may cause physical symptoms, such as a racing heart and shakiness.
Anxiety disorders are partly genetic but may also be due to drug use including alcohol & caffeine, as well as withdrawal from certain drugs. They often occur with other mental disorders, particularly major depressive disorder, bipolar disorder, certain personality disorders, and eating disorders. The term anxiety covers four aspects of experiences that an individual may have: mental apprehension, physical tension, physical symptoms and dissociative anxiety. The emotions present in anxiety disorders range from simple nervousness to bouts of terror. There are other psychiatric and medical problems that may mimic the symptoms of an anxiety disorder, such as hyperthyroidism.
There are a number of anxiety disorders including:
- generalized anxiety disorder
- a specific phobia
- social anxiety disorder
- separation anxiety disorder
- panic disorder among others.
While each has its own characteristics and symptoms, they all include symptoms of anxiety.
Common treatment options include lifestyle changes, therapy, and medications. Medications are typically recommended only if other measures are not effective. Anxiety disorders occur about twice as often in females as males, and generally begin during childhood.
Generalized anxiety disorder (GAD) is a common, chronic disorder characterized by long-lasting anxiety that is not focused on any one object or situation. Those suffering from generalized anxiety disorder experience non-specific persistent fear and worry, and become overly concerned with everyday matters. According to Schacter, Gilbert, and Wegner's book Psychology: Second Edition, generalized anxiety disorder is "characterized by chronic excessive worry accompanied by three or more of the following symptoms: restlessness, fatigue, concentration problems, irritability, muscle tension, and sleep disturbance". Generalized anxiety disorder is the most common anxiety disorder to affect older adults. Anxiety can be a symptom of a medical or substance abuse problem, and medical professionals must be aware of this. A diagnosis of GAD is made when a person has been excessively worried about an everyday problem for six months or more. A person may find that they have problems making daily decisions and remembering commitments as a result of lack of concentration/preoccupation with worry. Appearance looks strained, with increased sweating from the hands, feet, and axillae, and they may be tearful, which can suggest depression. Before a diagnosis of anxiety disorder is made, physicians must rule out drug-induced anxiety and other medical causes.
In children GAD may be associated with headaches, restlessness, abdominal pain, and heart palpitations. Typically it begins around 8 to 9 years of age.
The single largest category of anxiety disorders is that of phobic disorders, which includes all cases in which fear and anxiety are triggered by a specific stimulus or situation. Between 5% and 12% of the population worldwide suffer from phobic disorders. Sufferers typically anticipate terrifying consequences from encountering the object of their fear, which can be anything from an animal to a location to a bodily fluid to a particular situation. Sufferers understand that their fear is not proportional to the actual potential danger but still are overwhelmed by it.
With panic disorder, a person has brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, and/or difficulty breathing. These panic attacks, defined by the APA as fear or discomfort that abruptly arises and peaks in less than ten minutes, can last for several hours. Attacks can be triggered by stress, fear, or even exercise; the specific cause is not always apparent.
In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder requires that said attacks have chronic consequences: either worry over the attacks' potential implications, persistent fear of future attacks, or significant changes in behavior related to the attacks. As such, those suffering from panic disorder experience symptoms even outside specific panic episodes. Often, normal changes in heartbeat are noticed by a panic sufferer, leading them to think something is wrong with their heart or they are about to have another panic attack. In some cases, a heightened awareness (hypervigilance) of body functioning occurs during panic attacks, wherein any perceived physiological change is interpreted as a possible life-threatening illness (i.e., extreme hypochondriasis).
Agoraphobia is the specific anxiety about being in a place or situation where escape is difficult or embarrassing or where help may be unavailable. Agoraphobia is strongly linked with panic disorder and is often precipitated by the fear of having a panic attack. A common manifestation involves needing to be in constant view of a door or other escape route. In addition to the fears themselves, the term agoraphobia is often used to refer to avoidance behaviors that sufferers often develop. For example, following a panic attack while driving, someone suffering from agoraphobia may develop anxiety over driving and will therefore avoid driving. These avoidance behaviors can often have serious consequences and often reinforce the fear they are caused by.
Social anxiety disorder
Social anxiety disorder (SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. As with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.
Social physique anxiety (SPA) is a subtype of social anxiety. It is concern over the evaluation of one's body by others. SPA is common among adolescents, especially females.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is an anxiety disorder that results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse, bullying, or even a serious accident. It can also result from long-term (chronic) exposure to a severe stressor, for example soldiers who endure individual battles but cannot cope with continuous combat. Common symptoms include hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression. There are a number of treatments that form the basis of the care plan for those suffering with PTSD. Such treatments include cognitive behavioral therapy (CBT), psychotherapy and support from family and friends.
Posttraumatic stress disorder (PTSD) research began with Vietnam veterans, as well as natural and non natural disaster victims. Studies have found the degree of exposure to a disaster has been found to be the best predictor of PTSD.
Separation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety is a normal part of development in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder. Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe; in some instances, even a brief separation can produce panic. Treating a child earlier may prevent problems. This may include training the parents and family on how to deal with it. Often, the parents will reinforce the anxiety because they do not know how to properly work through it with the child. In addition to parent training and family therapy, medication, such as SSRI's, can be used to treat separation anxiety.
Situational anxiety is caused by new situations or changing events. It can also be caused by various events that make that particular individual uncomfortable. Its occurrence is very common. Often, an individual will experience panic attacks or extreme anxiety in specific situations. A situation that causes one individual to experience anxiety may not affect another individual at all. For example, some people become uneasy in crowds or tight spaces, so standing in a tightly packed line, say at the bank or a store register, may cause them to experience extreme anxiety, possibly a panic attack. Others, however, may experience anxiety when major changes in life occur, such as entering college, getting married, having children, etc.
Obsessive–compulsive disorder (OCD) is not classified as an anxiety disorder by the DSM-5 but is by the ICD-10. It was previously classified as an anxiety disorder in the DSM-4. It is a condition where the person has obsessions (distressing, persistent, and intrusive thoughts or images) and/or compulsions (urges to repeatedly perform specific acts or rituals), that are not caused by drugs or physical order, and which cause distress or social dysfunction. The compulsive rituals are personal rules followed to relieve the anxiety. OCD affects roughly 1-2% of adults (somewhat more women than men), and under 3% of children and adolescents.
A person with OCD knows that the symptoms are unreasonable and struggles against both the thoughts and the behavior. Their symptoms could be related to external events they fear (such as their home burning down because they forget to turn off the stove) or worry that they will behave inappropriately.
It is not certain why some people have OCD, but behavioral, cognitive, genetic, and neurobiological factors may be involved. Risk factors include family history, being single (although that may result from the disorder), and higher socioeconomic class or not being in paid employment. OCD is chronic, and although about 20% of people will overcome it, symptoms will at least reduce over time for most people (a further 50%).
Anxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety levels in some individuals. Caffeine, alcohol and benzodiazepine dependence can worsen or cause anxiety and panic attacks. Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to 2 years as part of a post-acute withdrawal syndrome, in about a quarter of people recovering from alcoholism.
There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet-laying are some of the jobs in which significant exposure to organic solvents may occur.
Ingestion of caffeine may cause or exacerbate anxiety disorders. A number of clinical studies have shown a positive association between caffeine and anxiogenic effects and/or panic disorder. Those with anxiety disorders can have high caffeine sensitivity.
Cannabis use is associated with anxiety disorders. However, the precise relationship between cannabis use and anxiety still needs to be established.
Anxiety disorders can arise in response to life stresses such as financial worries or chronic physical illness. Anxiety among adolescents and young adults is common due to the stresses of social interaction, evaluation, and body image. Anxiety is also common among older people who have dementia. On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia) as signs of anxiety.
GAD runs in families and is six times more common in the children of someone with the condition.
While anxiety arose as an adaptation, in modern times it is almost always thought of negatively in the context of anxiety disorders. People with these disorders have highly sensitive systems; hence, their systems tend to overreact to seemingly harmless stimuli. Sometimes anxiety disorders occur in those who have had traumatic youths, demonstrating an increased prevalence of anxiety when it appears a child will have a difficult future. In these cases, the disorder arises as a way to predict that the individual’s environment will continue to pose threats.
Persistence of anxiety
At a low level, anxiety is not a bad thing. In fact, the hormonal response to anxiety has evolved as a benefit, as it helps humans react to dangers. Researchers in evolutionary medicine believe this adaptation allows humans to realize there is a potential threat and to act accordingly in order to ensure greatest possibility of protection. It has actually been shown that those with low levels of anxiety have a greater risk of death than those with average levels. This is because the absence of fear can lead to injury or death. Additionally, patients with both anxiety and depression were found to have lower morbidity than those with depression alone. The functional significance of the symptoms associated with anxiety includes: greater alertness, quicker preparation for action, and reduced probability of missing threats. In the wild, vulnerable individuals, for example those who are hurt or pregnant, have a lower threshold for anxiety response, making them more alert. This demonstrates a lengthy evolutionary history of the anxiety response.
It has been theorized that high rates of anxiety are a reaction to how the social environment has changed from the Paleolithic era. For example, in the Stone Age there was greater skin-to-skin contact and more handling of babies by their mothers, both of which are strategies that reduce anxiety. Additionally, there is greater interaction with strangers in present times as opposed to interactions solely between close-knit tribes. Researchers posit that the lack of constant social interaction, especially in the formative years, is a driving cause of high rates of anxiety.
Many current cases are likely to have resulted from an evolutionary mismatch, which has been specifically been termed a "psychopathogical mismatch." In evolutionary terms, a mismatch occurs when an individual possesses traits that were adapted for an environment that differs from the individual’s current environment. For example, even though an anxiety reaction may have been evolved to help with life-threatening situations, for highly sensitized individuals in Westernized cultures simply hearing bad news can elicit a strong reaction.
An evolutionary perspective may provide insight into alternatives to current clinical treatment methods for anxiety disorders. Simply knowing some anxiety is beneficial may alleviate some of the panic associated with mild conditions. Some researchers believe that, in theory, anxiety can be mediated by reducing a patient’s feeling of vulnerability and then changing their appraisal of the situation.
Low levels of GABA, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by modulating the GABA receptors.
Selective serotonin reuptake inhibitors, the drugs most commonly used to treat depression, are frequently considered as a first line treatment for anxiety disorders.
The amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders. Sensory information enters the amygdala through the nuclei of the basolateral complex (consisting of lateral, basal, and accessory basal nuclei). The basolateral complex processes sensory-related fear memories and communicates their threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.
Another important area is the adjacent central nucleus of the amygdala, which controls species-specific fear responses, via connections to the brainstem, hypothalamus, and cerebellum areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex circuits that underlie executive functions.
The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. Researchers have noted "Amygdalofrontoparietal coupling in generalized anxiety disorder patients may ... reflect the habitual engagement of a cognitive control system to regulate excessive anxiety." This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.
Clinical and animal studies suggest a correlation between anxiety disorders and difficulty in maintaining balance. A possible mechanism is malfunction in the parabrachial area, a brain structure that, among other functions, coordinates signals from the amygdala with input concerning balance.
Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization. By overexpressing SK2 in the basolateral amygdala, anxiety in experimental animals can be reduced together with general levels of stress-induced corticosterone secretion.
Focus is increasing on prevention of anxiety disorders. There is tentative evidence to support the use of cognitive behavior therapy and mindfulness therapy. As of 2013, there are no effective measures to prevent GAD in adults.
Anxiety disorders are often severe chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress and are frequently accompanied by physiological symptoms such as headache, sweating, muscle spasms, tachycardia, palpitations, and hypertension, which in some cases lead to fatigue or exhaustion.
In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat. The term "anxiety disorder" includes fears (phobias) as well as anxieties.
Standardized screening clinical questionnaires such as the Taylor Manifest Anxiety Scale or the Zung Self-Rating Anxiety Scale can be used to detect anxiety symptoms, and suggest the need for a formal diagnostic assessment of anxiety disorder.
Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.
Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.
Sexual dysfunction often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.
Treatment options available include lifestyle changes, therapy, and medications. Medication are only recommended if other measures are not effective. Stopping smoking has benefits in anxiety as large as or larger than those of medications. Reducing caffeine intake and regular exercise are also useful measures.
Cognitive behavioral therapy (CBT) is effective for anxiety disorders. CBT appears to be equally effective when carried out via the internet.
In social phobia a specific form of short-term CBT, the central component being gradual exposure therapy. Self-help books can contribute to the treatment of people with anxiety disorders.
Mindfulness based programs also appear to be effective for managing anxiety disorders. It is unclear if meditation has an effect on anxiety and transcendental meditation appears to be no different than other types of meditation.
Treatment controversy arises because while some studies indicate that a combination of medication and psychotherapy can be more effective than either one alone, others suggest medications have little added benefit for some patients, are largely palliative, and/or can actually interfere with the mechanisms of successful therapy (e.g., benzodiazepines). Psychotherapeutic interventions have better long-term efficacy compared to pharmacotherapy.
Due to shared biological characteristics between depression and anxiety, antidepressants are the first-line medication treatment for anxiety disorders. While psychotherapy is generally the preferred treatment for anxiety due to efficacy and low side effect risks, medications are often used to augment psychotherapy or when an individual declines other treatments (e.g., due to avoidance of talking about anxiety-provoking material). If medications are to be used, SSRIs are recommended as first-line agents. MAOIs such as phenelzine and tranylcypromine are considered an effective treatment and are especially useful in treatment-resistant cases, however, dietary restrictions and medical interactions may limit their use.
In children and adolescents, when a medication option is warranted, antidepressants such as SSRIs, SNRIs as well as tricyclic antidepressants can be effective. The effectiveness and increased suicide risk of SSRIs among children and adolescents has been subject to controversy. General side effects are common and may include headaches, nausea, insomnia, and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a possible link between SSRI use and suicide. In 2005, Food and Drug Administration (FDA) conducted a comprehensive review based on 372 placebo-controlled trials involving almost 100,000 patients and issued a warning to general public regarding the correlation between the use of SSRIs and increased risk of suicide in younger adults. In 2006, FDA's Psychopharmacologic Drugs Advisory Committee concluded that labelling changes were required to inform health care professionals and general public about the potential risks of suicide.
These medications need to be used with care among older adults, who are more likely to have side effects because of coexisting physical disorders. Adherence problems are more likely among elderly patients, who may have difficulty understanding, seeing, or remembering instructions.
Foods to eat
The foods you eat play an important role in how effectively your nervous system operates and consequently how relaxed or stress you feel throughout the day.
High sugar and refined grain foods negatively affect your blood sugar levels and can generally be considered stress promoting. Conversely, natural foods like vegetables, nuts and healthy protein sources are much slower digesting and usually provide a calmer and significantly more stable energy.
Caffeine can cause anxiety, along with more minor effects such as muscle twitching, hand tremors, and headaches. The best way to prevent caffeinism is to either wean off caffeine completely or reduce consumption. For some people, anxiety can be reduced by coming off caffeine. Anxiety can temporarily increase during caffeine withdrawal.
There a certain anti-anxiety foods that are particularly good at reducing stress levels and relaxing your body and mind. Ahead are ten of the best foods for relieving anxiety and tension. Read More: https://www.healthambition.com/top-10-anti-anxiety-foods/
Regular exercise and reducing caffeine are often useful in treating anxiety. A 2006 review found a small but tentative benefit of exercise for anxiety in children. There is tentative evidence that yoga may be effective. A 2010 review concluded the evidence was promising.
Many other remedies have been used for anxiety disorder. These include kava, where the potential for benefit seems greater than that for harm with short-term use in those with mild to moderate anxiety. The American Academy of Family Physicians (AAFP) recommends use of kava for those with mild to moderate anxiety disorders who are not using alcohol or taking other medicines metabolized by the liver, but who wish to use "natural" remedies. Side effects of kava in the clinical trials were rare and mild.
Inositol has been found to have modest effects in people with panic disorder or obsessive-compulsive disorder. There is insufficient evidence to support the use of St. John's wort, valerian or passionflower.
Aromatherapy has shown some tentative benefits for anxiety reduction in people with cancer when done with massages, although it not clear whether it could just enhance the effect of massage itself.
The prognosis varies on the severity of each case and utilization of treatment for each individual. If these children are left untreated, they face risks such as poor results at school, avoidance of important social activities, and substance abuse. Children who have an anxiety disorder are likely to have other disorders such as depression, eating disorders, attention deficit disorders both hyperactive and inattentive.
Globally as of 2010 approximately 273 million (4.5% of the population) had an anxiety disorder. It is more common in females (5.2%) than males (2.8%). In Africa, lifetime rates of anxiety disorders are between 9 and 16%, and yearly rates are between 4 and 7%.
Like adults, children can experience anxiety disorders; between 10 and 20 percent of all children will develop a full-fledged anxiety disorder prior to the age of 18, making anxiety the most common mental health issue in young people. Anxiety disorders in children are often more challenging to identify than their adult counterparts owing to the difficulty many parents face in discerning them from normal childhood fears. Likewise, anxiety in children is sometimes misdiagnosed as an attention deficit disorder or, due to the tendency of children to interpret their emotions physically (as stomach aches, head aches, etc.), anxiety disorders may initially be confused with physical ailments.
Anxiety in children has a variety of causes; sometimes anxiety is rooted in biology, and may be a product of another existing condition, such as Autism or Asperger's Disorder. Gifted children are also often more prone to excessive anxiety than non-gifted children. Other cases of anxiety arise from the child having experienced a traumatic event of some kind, and in some cases, the cause of the child's anxiety cannot be pinpointed.
Anxiety in children tends to manifest along age-appropriate themes, such as fear of going to school (not related to bullying) or not performing well enough at school, fear of social rejection, fear of something happening to loved ones, etc. What separates disordered anxiety from normal childhood anxiety is the duration and intensity of the fears involved.
A small child will usually experience separation anxiety, for example, but he or she will generally grow out of it by about the age of 6, whereas in an anxious child it may linger for years longer, hindering the child's development. Similarly, most children will fear the dark or losing their parents at some point, but this fear will dissipate over time without interfering a great deal in that child's normal day-to-day activities. In a child with an anxiety disorder, fearing the dark or loss of loved ones may grow into a lasting obsession which the child tries to deal with in compulsive ways which erode his or her quality of life.
Children, similar to adults, may suffer from a range of different anxiety disorders, including:
- Generalized anxiety disorder: The child experiences persistent anxiety regarding a wide variety of situations, and this anxiety may adapt to fit each new situation that arises or be based largely on imagined situations which have yet to occur. Reassurance often has little effect.
- Separation anxiety disorder: A child who is older than 6 or 7 who has an extremely difficult time being away from his or her parents may be experiencing Separation Anxiety Disorder. Children with this disorder often fear that they will lose their loved ones during times of absence. As such, they frequently refuse to attend school.
- Social anxiety disorder should not be confused with shyness or introversion; shyness is frequently normal, especially in very young children. Children with social anxiety disorder often wish to engage in social activity (unlike introverts) but find themselves held back by obsessive fears of being disliked. They often convince themselves they have made a poor impression on others, regardless of evidence to the contrary. Over time, they may develop a phobia of social situations. This disorder affects older children and preteens more often than younger children. Social phobia in children may also be caused by some traumatic event, such as not knowing an answer when called on in class.
While uncommon in children, OCD can occur. Rates are between two and four percent. Like adults, children rely on "magical thinking" in order to allay their anxiety, i.e., he or she must perform certain rituals (often based in counting, organizing, cleaning, etc.) in order to "prevent" the calamity he or she feels is imminent. Unlike normal children, who can leave their magical thinking-based activities behind when called upon to do so, children with OCD are literally unable to cease engaging in these activities, regardless of the consequences.
Panic disorder is more common in older children, though younger children sometimes also suffer from it. Panic disorder is frequently mistaken for a physical illness by children suffering from it, likely due to its strongly physical symptoms (a racing heartbeat, sweating, dizziness, nausea, etc.) These symptoms are, however, usually accompanied by extreme fear, particularly the fear of dying. Like adults with Panic Disorder, children may attempt to avoid any situation they feel is a "trigger" for their attacks.
Several methods of treatment have been found to be effective in treating childhood anxiety disorders. Cognitive behavioral therapy (CBT), a well-established treatment for anxiety related disorders in children and adolescents, is a good first therapy approach. Studies have also gathered substantial evidence for treatments that are not CBT based as being effective forms of treament, expanding treatment options for those who do not respond to CBT. Like adults, children may undergo psychotherapy, cognitive-behavioral therapy, or counseling.
The following forms of treatment have become increasingly popular:
- Family therapy is a form of treatment in which the child meets with a therapist together with the primary guardians and siblings. Each family member may attend individual therapy, but family therapy is typically a form of group therapy.
- Art and play therapy are also used. Art therapy is most commonly used when the child will not or cannot verbally communicate, due to trauma or a disability in which they are nonverbal. Participating in art activities allows the child to express what they otherwise may not be able to communicate to others. In play therapy, the child is allowed to play however they please as a therapist observes them. The therapist may intercede from time to time with a question, comment, or suggestion. This is often most effective when the family of the child plays a significant role in the treatment.