Anxiety Disorders
Marianne San Antonio
Nili E. Major
I. Description of the problem. Anxiety is commonly a normal part of child development. The occurrence of stranger anxiety in the first year of life is an early example of what is developmentally appropriate anxiety. Fears about monsters and the dark are common in preschoolaged children, whereas school-aged children typically worry about injury and natural events (e.g., storms). Older children and adolescents often have worries about school performance and social competence. Distinguishing among normal fears and worries, temperamental variations, and clinically significant anxiety may be challenging. However, anxiety disorders are common in the pediatric population, and efforts to identify these children should be made, as effective, evidence-based treatments are available. Anxiety disorders in children are characterized by excessive and developmentally inappropriate worry that significantly impairs the child’s functioning. The context in which anxiety symptoms are produced primarily differentiates the specific anxiety disorders. Below are commonly encountered specific disorders. Other anxiety disorders such as post-traumatic stress disorder, specific phobias, and selective mutism are discussed elsewhere in this book.
A. Anxiety disorders.
1. Generalized anxiety disorder (GAD) is characterized by chronic and excessive worry in a number of areas (e.g., schoolwork, social interactions, family, health/safety, world events) that is difficult to control.
2. Separation anxiety disorder (SAD) refers to excessive and developmentally inappropriate distress experienced when separated from home or major attachment figures.
3. Social phobia is characterized by feeling scared or uncomfortable in social and performance situations due to fear of embarrassment.
4. Obsessive compulsive disorder (OCD) is defined by the presence of obsessions or compulsions that cause marked distress, are time consuming (occupy a child for more than 1 hour a day), or significantly interfere with the child’s normal functioning.
B. Epidemiology. Anxiety disorders are among the most common psychiatric disorders affecting children and adolescents. The lifetime prevalence for having any anxiety disorder ranges from 6%-20% across several large-scale epidemiological studies. Anxiety disorders are typically more frequent in girls than in boys, with ratios of 2:1 to 3:1 by adolescence. Anxiety disorders may begin at any time, but more than 70% of adults diagnosed with an anxiety disorder report that their symptoms started in childhood. The average age of onset for specific anxiety disorders varies widely among studies. Likewise, the long-term course of anxiety disorders diagnosed in childhood is somewhat controversial. In general, the more severe and impairing the disorder, the more likely it is to persist. Despite the remission of some initial disorders, new anxiety disorders may emerge over time. Also, there is an increased risk for later development of other disorders, such as depression and substance abuse. Anxiety disorders are highly comorbid with other anxiety disorders, as well as with other psychiatric disorders, such as attention-deficit/hyperactivity disorder, depression, substance abuse, oppositional defiant disorder, learning disorders, and language disorders.
1. GAD. Reported prevalence rates range from 3%-5%. GAD is often highly comorbid with depression, leading to some speculation as to whether they are truly distinct disorders. Children with comorbid depression often have a poorer prognosis and longer duration of symptoms.
2. SAD. SAD is the only anxiety disorder considered to be specific to childhood, as its onset must occur prior to 18 years of age. Prevalence rates are estimated to be between 3% and 5%. Although SAD typically has the highest remission rate of all the anxiety disorders, it remains a risk factor for the later development of anxiety and depressive disorders.
3. Social phobia. The rate of lifetime social phobia in a community sample of adolescents was found to be 1.6%. There is evidence that social phobia in adolescents is a unique risk factor for the development of subsequent substance dependence disorders.
4. OCD. Prevalence of OCD ranges from 1%-4% in children and adolescents. In childhood, OCD is more common in boys with a ratio of 3:2. This changes to a slight female predominance in adulthood. Tic disorders are a common comorbid condition in children with OCD.
C. Etiology.
1. Genetic. Although there are no specifically identified genes in humans for anxiety disorders, children who have a first-degree relative with an anxiety disorder are more likely to develop one themselves. Based on twin studies, estimated genetic heritabilities are modest, falling in the range of 30%-40%. Current research is looking at candidate genes in mouse models and biochemical functioning in the amygdala as possible sources of these disorders.
2. Environmental. Families can play a role in a child’s development of an anxiety disorder by modeling anxious behaviors. Parents may reinforce a child’s avoidant behaviors, thereby increasing their frequency. Parents who are overinvolved, controlling, or highly critical of their children may also contribute to anxiety in their children. Transitions and losses, such as moving, the death of a relative, or a parent who loses a job, can also trigger anxiety in children. It is important to keep in mind that anxiety in a child can be a red flag for significant stress or violence in the home.
3. Temperament. Children with a temperamental style known as behavioral inhibition are at increased risk for the development of anxiety disorders, particularly social phobia. These children typically exhibit fearfulness and withdrawal when faced with new people and situations.
II. Making the diagnosis.
A. Signs and symptoms. The various anxiety disorders discussed here often share commonalities in their presentations. Children will frequently report somatic complaints. Anger, irritability, and crying are often present when the child is confronted with the fearful stimuli and may be misconstrued as oppositional behavior. The anxiety symptoms interfere with the child’s normal functioning in school, with friends, and in the home. Common clinical presentations of the individual anxiety disorders are presented below, along with specific information regarding Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria (with special attention paid to differences in criteria that pertain to diagnosis in children).
1. GAD. Children with GAD have anxiety and worry about a wide range of topics that is difficult for them to control. They are often conforming perfectionists who constantly seek approval and reassurance. Anxieties may take different forms at different ages:
Preschool: imaginary creatures
5-6 years: threats to physical well-being
7-14 years: school performance, health, personal harm
Adolescent: social issues
Symptoms must be present for at least 6 months. In children, only one associated symptom listed in the DSM-IV-TR is required for diagnosis.
2. SAD. Children with SAD exhibit distress when faced with separation from major attachment figures. Parents often note that their children with SAD
Follow them around the house
Refuse to be alone to sleep or to use the bathroom
Often worry excessively about their parents’ safety and health
Experience nightmares with themes of separation
When away from home, are extremely homesick and fear being lost
Refuse to go to school or to camp
Experience stomachaches and headaches on weekdays but not weekends
According to DSM-IV-TR criteria, symptoms must be present for at least 4 weeks, and onset must be prior to 18 years of age. Although SAD is considered a childhood disorder, symptoms may be present in adults as well.
3. Social phobia. Children with social phobia experience fear associated with social scrutiny in social settings such as classrooms, restaurants, and extracurricular activities. These children may have difficulty reading aloud or answering questions in class, initiating conversations, eating at restaurants, using public restrooms, and attending social events. The duration of symptoms must be at least 6 months. There are a number of clarifications in the DSM-IV-TR pertaining to making this diagnosis in children:
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