Although fears and anxiety occur normally during development (Table 7–1), anxiety disorders in children remain underrecognized and undertreated and can lead to lack of social competence, rejection or neglect by peers, academic underachievement, and eventual reduced occupational and social relationship functioning. In contrast to the disruptive behavior disorders, anxiety disorders often cause more distress in the child than in the parents and are thus considered “internalizing” disorders. The Anxiety Disorders Interview Schedule for Children and Parents (ADIS; Silverman et al. 2001) is a semistructured interview that clinicians may use to evaluate many anxiety disorders.
Feared object or situation
Birth to 6 months
Loss of physical support
Large rapidly approaching objects
Separation from parents
Being sent to the principal
Tests in school
Low social competence
SEPARATION ANXIETY DISORDER
Separation anxiety disorder (SAD) was moved to the anxiety disorders section in DSM-5 (American Psychiatric Association 2013). The core symptoms remain essentially the same, but the description was expanded to include adult separation anxiety disorder (e.g., the adult’s attachment figure may be the child). Onset no longer is required to be before 18 years of age, and the disorder may occur in adulthood. The required duration remains at least 4 weeks for children and adolescents but was increased to at least 6 months in adults. In SAD, cognitive, affective, somatic, and behavioral symptoms appear in response to genuine or fantasized separation from the individual(s) to whom the child is most attached. The key feature of SAD is excessive and age-inappropriate anxiety, fear, or worry concerning separation from home or primary attachment figures (Box 7–1). The anxiety can be experienced and expressed as an unrealistic fear of or worry about the child and parent being permanently separated due to injury, kidnapping, harm, or death. Symptoms can include nightmares with separation themes and inability to sleep alone, attend school, visit friends, go on errands, or stay at camp. To avoid leaving home, children with SAD will often complain of somatic symptoms such as stomachaches or headaches (which they may actually be experiencing) or report distressing events such as bullying by peers or being picked on by teachers.
Box 7–1 DSM-5 Diagnostic Criteria for Separation Anxiety Disorder
- Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
- Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
- Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
- Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
- Repeated nightmares involving the theme of separation.
- Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents.
- The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
- The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
Not all children with SAD miss excessive amounts of school, and not all children with school absenteeism have SAD. However, school refusal often occurs within the context of psychiatric disorders, psychosocial vulnerabilities, impaired family functioning, parental psychopathology, and/or stressful life events. Approximately three-quarters of children with SAD exhibit school avoidance (Last et al. 1987). School absenteeism has various etiologies (Table 7–2). In clinical samples of children and adolescents with school refusal, anxiety and depressive disorders, alone or in combination, are very common.
Separation anxiety disorder
Other psychiatric disorders
Generalized anxiety disorder
Social anxiety disorder
Truancy (often associated with conduct disorder)
Permission granted by family (overt or covert)
Normative peer behavior
Excessive teasing/humiliation or verbal harassment/bullying
Physical bullying—intimidation or bodily harm
Academic struggles or avoidance
SAD has a reported prevalence of 3%–5% in youth (Shear et al. 2006), with higher prevalence in childhood compared with adolescence (Breton et al. 1999) and much higher rates of symptoms that do not meet full diagnostic criteria (Kashani and Orvaschel 1990). More recent research has shown that females have a higher prevalence of SAD than males, in contrast to older studies that found no gender differences. As with other anxiety disorders, SAD appears to aggregate in families.
A variety of theoretical perspectives exist on the etiology of SAD. The high familial concordance of anxiety disorders makes it difficult to separate the contributions of genetic inheritance, temperament, family dynamics, modeling, and other environmental factors. An interactive mechanism is most likely.
Developmental theorists focus on the interplay between the exploring toddler’s normal uncertainty about the location of the caregiver and the at-risk child’s anxious or insecure attachment. Behaviorally oriented theories emphasize the maintenance of symptoms by conditioned fear, based on stimulus generalization and reinforcement. Research using an attachment theory model found that insecure mother-infant attachment and maternal sensitivity each separately predicted separation anxiety in children at age 6 years (Dallaire and Weinraub 2005).
Biological theories focus on temperamental, genetic, and physiological factors. More specifically, research reveals age-specific effects of both genes and shared environment on anxiety, depression, and withdrawn behavior in childhood and adolescence (Lamb et al. 2010). SAD and other anxiety disorders may be linked to dysregulation of the fear and stress response system in the brain (Bagnell 2011). Mood and/or anxiety disorders are commonly found in the parents and other relatives of children with SAD. A possible subtype of SAD has been identified in children who may be at particularly high risk for developing panic disorder as adults (Roberson-Nay et al. 2010). Behavioral inhibition as described by Kagan (1998) refers to a genetically based temperament trait characterized by response to a new or unfamiliar situation with avoidance, distress, caution, and/or reticence. Both family studies of subjects with anxiety disorders and prospective studies of toddlers have found that behavioral inhibition is correlated with increased risk of developing anxiety disorders. Specific parenting styles characterized by rejection, control, and intrusiveness are also likely related to increased anxiety in youth (Rapee 1997; Wood 2006).
Course and Prognosis
SAD typically begins around the age of school entry and is usually recognized in early or middle childhood. The disorder is often recurrent, with acute exacerbations at the beginning of the school year, following holiday breaks from school, or when starting a new school. Early predictors of SAD include parental depression, parental panic disorder, and strong stranger anxiety during infancy (Lavallee et al. 2011). Precipitants include actual separations, parental divorce, deaths, family moves, family changes, and family crises. Symptoms may worsen during or after medical illnesses or procedures. Comorbidity with other anxiety disorders and non-anxiety psychiatric disorders is common, although rates vary among studies.
Most children who suffer from SAD do not receive mental health treatment. A substantial proportion of children with SAD eventually recover, with or without treatment. Others experience repeated remissions and relapses and may develop a chronic course with impairment extending into adulthood. Adults with SAD typically have a history of childhood SAD (Silove et al. 2010). In addition to suggested links between childhood SAD and adult agoraphobia or panic disorder, SAD may be considered a risk factor for subsequent depression and other anxiety disorders (Lewinsohn et al. 2008).
Follow-up studies of childhood school absenteeism have reported a high prevalence of adult maladaptation and psychiatric symptoms. Although many of these children return to school eventually, poor overall emotional and social functioning is common. School absentees often have academic underachievement and social avoidance and can be at risk for excessive absenteeism from work or chronic unemployment in adulthood.
Evaluation and Differential Diagnosis
A parent may need to be present with the child for the entire initial interview, if separation is too difficult. Evaluation should include probing for symptoms of anxiety or mood disorders in both the child and the parents, assessing for syndromes that may mimic anxiety. Rating scales such as the Multidimensional Anxiety Scale for Children–2 (MASC-2), by John March (available from Multi-Health Systems), or the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al. 1997) are useful in quantifying symptoms. Physical symptoms such as nausea, vomiting, abdominal pain, or headaches require judicious medical evaluation. In SAD, somatic symptoms are typically worse on evenings and mornings before school and absent on weekends and holidays, except as separations approach. A careful focus is needed on identifying any factors contributing to school refusal, using multiple informants (child, parent, teacher, and other school staff).
Separation anxiety is a normal developmental phenomenon in children ages 6–30 months, with intensification between 13 and 18 months of age (Kearney et al. 2003). In children younger than 6 years, normal separation anxiety can reappear in stressful situations. In an older child, this may represent an adjustment disorder with anxiety. Other anxiety disorders in the differential diagnosis include generalized anxiety disorder (GAD), panic disorder, and social anxiety disorder. A depressive disorder may also cause clinginess and refusal to separate from the parent. Less commonly, children with schizophrenia or an autism spectrum disorder may present with symptoms of separation anxiety.
When evaluating the patient with chronic school absenteeism, the clinician should investigate possible causes other than separation anxiety disorder (see Table 7–2). The most common cause of school absenteeism in adolescents is truancy, a feature of conduct disorder. Youngsters with truancy typically show delinquent behavior. They may leave home in the morning and spend the day with friends, while their parents are unaware of or not concerned about their activities, in contrast to children with SAD, who remain at home with their parents’ knowledge.
SAD is treated using a multimodal approach, including psychoeducation (see Appendix, “Resources for Parents”), collaboration with the primary care provider, school consultation, cognitive-behavioral therapy (CBT), family therapy, and selective serotonin reuptake inhibitors (SSRIs).
School absenteeism requires prompt intervention because, regardless of the cause, the longer the child is out of school, the higher the likelihood of treatment resistance, chronicity, and school failure. The goals are age-appropriate separation of parent and child and a rapid return to school. Cooperation of the family and the school is essential.
For psychotherapy of SAD in youth, CBT has strongest empirical support (Kearney and Albano 2000; Velting et al. 2004). Key elements are psychoeducation of parents and youth, management of somatic symptoms, relaxation training, cognitive restructuring, behavioral exposures, contracting and contingency management, social skills training, and relapse prevention. Specific techniques include using limit setting, eliminating secondary gain for staying home, escorting the child to school, incorporating gradual exposure to increasing lengths of time at school, and rewarding the child for increasing successful attendance. Parent-child interaction therapy (PCIT) is another effective treatment for younger children (Pincus et al. 2005).
Multimodal treatment planning for youth with SAD must be done sensitively, with understanding of the child’s symptoms and concerns. Home schooling is contraindicated, but proactive problem-solving around any actual school issues, such as bullying, is essential. If the child also has panic disorder or a major depressive episode, aggressive return to school prior to addressing these comorbid issues can exacerbate symptoms. A thoughtful treatment plan for school reentry includes planning calm and predictable morning routines, encouraging children and parents to use new cognitive-behavioral skills, addressing positive and/or negative reinforcement of school refusal behavior, and ensuring safety in the environment (such as a school social worker providing support during the school day). Classroom-based accommodations and modifications may also be appropriate under an Individualized Education Plan or Response to Intervention planning.
When moderate to severe anxiety symptoms persist despite appropriate psychosocial and family-based therapeutic interventions, an antidepressant may be added to the treatment of separation anxiety or comorbid mood disorder. SSRIs (see Chapter 17, “Psychopharmacology”) have replaced imipramine and other tricyclic antidepressants as a result of their more favorable side-effect profile and improved tolerability. The age of the child should always be taken into consideration. Older children are more commonly treated with medication than younger children. Benzodiazepines have been used rarely in youth as adjuncts to psychological interventions, although behavioral disinhibition, sedation, and dependence/withdrawal are serious potential side effects. These agents should be used sparingly, temporarily, and in combination with an SSRI, if at all.
Given the enhanced outcomes of combination treatment (sertraline plus CBT) compared with either treatment alone in a large randomized study (Walkup et al. 2008), an SSRI plus CBT is recommended for youth with SAD, GAD, and/or social anxiety disorder. However, depending on availability, cost, time factors, and family preference, an SSRI alone, CBT alone, or the combination may be selected in an individual case.
SAD-related sleep disturbance or resistance to sleeping alone is generally treated behaviorally. Techniques include developing a predictable and calming bedtime routine, monitoring bedtime behavior, teaching the child relaxation and other coping skills, and supporting parents while coaching them to positively reinforce the child for sleeping in his or her own bed (McMenamy and Katz 1989).
If a parent’s own anxiety or mood disorder is making it harder to separate from the child, the parent should also receive direct psychiatric treatment (possibly including appropriate medication) in addition to guidance in child management and parenting in the context of individual or family therapy.
Common issues in any modality of treatment of SAD are planned and unplanned absences (e.g., vacations by the patient or therapist, school transitions, parental absence, losses of people important to the child) and the termination of treatment. Anticipatory guidance for the parents and the child regarding expected separations is useful. Once treatment is completed, the therapist should be specific about when and how to return to treatment, for example at times of increased vulnerability or if symptoms return.
Referral to a partial hospitalization program (PHP) (day treatment) (see Chapter 18, “Psychosocial Treatments”) may be warranted as a transition to school reentry, particularly if school refusal persists despite adequate outpatient treatment. Severe SAD that results in total avoidance of school and does not respond to environmental, psychotherapeutic, and pharmacological interventions may require psychiatric hospitalization. However, prompt referral to a PHP can often avoid the need for inpatient hospitalization. When available, intensive outpatient programs (IOP) that offer treatment several days a week (typically after school) can also be useful as a “step up” from traditional outpatient care if more intensive treatment is needed, or as a “step down” to ease the transition to school reentry following hospitalization or PHP.
In the treatment of adolescents with truancy, firm limit setting with supervision and contingency contracting is necessary. When school absenteeism includes family permission, socializing with peers, risk of physical danger, or substance abuse, involvement of juvenile authorities may be needed.
In DSM-5 (American Psychiatric Association 2013), selective mutism (SM) was placed in the anxiety disorders section. Children with SM do not speak in one or several important settings despite having the ability to comprehend spoken language and to speak in other situations. Symptoms persist for at least 1 month (outside of the first month of school when transient mutism can occur) and are severe enough to affect educational and interpersonal functioning. These children have an adequate knowledge of the language yet may experience specific developmental communication disorders. Typically, speech is normal at home when the child is alone with parents and siblings, but partial or total muteness appears in the presence of teachers, peers, and strangers or selectively in unfamiliar places or particular social situations. When these children are separated from a familiar or comfortable setting, they might use gestures, nods, monosyllabic responses, written notes, or whispers but avoid full vocalization. Many of these children are shy, anxious, withdrawn, socially inhibited, fearful of new experiences, and resistant to separation from parents. Some have oppositional behavior, as well.
SM is estimated to occur in a very small percentage of school-age children and typically begins between 3 and 8 years of age. Point prevalence ranges from 0.03% to 1%, depending on the age of the population studied, setting of study, and the length of their exposure to school. Prevalence is higher in younger children than in adolescents. There is no difference in the prevalence due to sex, race, or ethnicity, but a higher prevalence rate of 2% was reported in immigrant families (Elizur and Perednik 2003).
Genetic, temperamental, environmental, and developmental factors all contribute to the development of SM. Family aggregation of SM and related symptoms (social anxiety, shyness, or speech and language disorders) suggests that genetic factors may contribute to the development of SM (Keeton and Crosby Budinger 2012). There is an association between a temperament marked by behavioral inhibition and SM (Muris et al. 2016). SM is seen at higher rates in bilingual children of immigrant families. It can be challenging to distinguish SM from a typical “silent period” of newly immigrated children, but SM should be suspected if the mutism is prolonged despite adequate exposure to the host language, if SM exists in both languages, or if there is associated anxiety or inhibited behavior (Toppelberg et al. 2005).
There may be a link between SM in children and social anxiety disorder in adults. These adults recall feeling intensely anxious as children when they were asked to speak, with accompanying symptoms that approximate panic. SM may have been an early observable form of developing social anxiety disorder. Parents of selectively mute children tend to have a variety of anxiety disorders, including panic, separation anxiety, and social anxiety.
Selectively mute children have higher rates of many developmental conditions, including elimination disorders, motor delays, and lower intelligence quotient (Kristensen 2000). Approximately 25% of children with SM also had delayed onset of speech, and 50% have a speech disorder or speech immaturities. These associations suggest that there is a neurodevelopmental etiology or that developmental disorders may worsen communication impairments. Global mutism can result from cerebellar lesions and is known to accompany cerebellar hemorrhages, subarachnoid hemorrhages, vertebral artery injuries, basilar artery occlusion, and head trauma.
Course and Prognosis
SM is usually discovered when the child attends kindergarten or first grade and is expected to speak. Excessive shyness may be identified retrospectively. The diagnosis is typically made between 3 and 8 years of age. Symptoms may last for weeks, months, or years and usually resolve by age 10. When SM persists beyond age 12, patients are less likely to completely recover. Complications of SM include academic underachievement and impaired peer relationships. The child’s persistent silence may lead to unhelpful special class and school placements. Many of these children have comorbid psychiatric problems, including social anxiety disorder, obsessive-compulsive disorder, or school avoidance. In clinically referred samples, some patients have comorbid oppositional defiant disorder. Social anxiety disorder may emerge in adulthood.
Evaluation and Differential Diagnosis
Standard psychiatric evaluation is indicated, including family history of language or anxiety disorders. Speech and language evaluation is warranted. The clinician should review the child’s medical history for evidence of neurological injury or delay or hearing deficit, with neurological evaluation or audiological testing if indicated. Although the child may not speak directly to the clinician, observation of the quality of interaction and ability to communicate nonverbally can yield valuable information. The clinician should evaluate the possible presence of physical or sexual abuse, depression, and anxiety disorders.
The differential diagnosis of failure to speak includes hearing impairment, intellectual disability, communication disorder, aphasia, autism spectrum disorder, schizophrenia, and conversion disorder. Global impairment of speech is characteristic of all but the latter three disorders.
First-line treatment is behavioral, combining office-based desensitization with active involvement of parents at home and teachers at school (Cohan et al. 2006). Speech and language therapy is often needed, as well. Therapy is based on the assumption that the child will speak again. Any form of communication is encouraged through behavioral plans that shape behavior by reinforcing attempts to speak. Short-term therapy may be effective, although in more resistant cases longer-term treatment may be required. Family therapy may help to identify and change dysfunctional patterns that maintain symptoms. Although teachers and parents often make accommodations to the child’s muteness, it is better to maintain a clear expectation that the child talk and communicate, at least for a structured period of each session. The parents should be explicit with the child about these expectations: to talk at school and in therapy.
In cases resistant to psychosocial approaches and with more pronounced anxiety symptoms, there is some evidence to support pharmacologic treatment with fluoxetine or sertraline.
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) AND SPECIFIC PHOBIAS
A specific phobia is defined as marked fear or anxiety about a specific object or situation. In DSM-5 (American Psychiatric Association 2013), there is no longer a distinction between pediatric and adult criteria for specific phobia and social anxiety disorder. At all ages, the anxiety must be out of proportion to the actual danger or threat in the situation, after cultural contextual factors are taken into account. A 6-month duration is required. Transient developmentally appropriate fears (see Table 7–1) do not usually require treatment. Phobias are distinguished from normal fears by their severity, irrationality, persistence, and functional impairment, usually secondary to avoidance of the feared object or situation. Persons with social anxiety disorder suffer from marked fear or anxiety about one or more social situations in which they are exposed to possible scrutiny and negative evaluation by others. DSM-5 examples include interacting socially, being observed (e.g., eating), and performing in front of others (e.g., reading aloud in class, giving a speech).
Many children with phobias are never seen in a clinical setting because parents and teachers rarely refer children with anxiety or excessive shyness for treatment. The prevalence of specific phobias is 5% in children and 16% in 13- to 17-year-olds (American Psychiatric Association 2013). Most phobias are more common among girls and younger children, though gender rates are equal for blood-injection-injury phobia. Social anxiety disorder is estimated to occur in 2%–5% of youth (March et al. 2007), though an epidemiological study of adolescents and young adults found the prevalence to be about 9% (Burstein et al. 2011). Lifetime prevalence in the general population may be as high as 16% (Lipsitz and Schneier 2000). While nonreferred youth with specific phobia generally have less comorbidity than do those with other anxiety disorders, the children who do present for treatment tend to be more symptomatic with regard to both anxiety and comorbidities.
Contributions to the development of childhood anxiety include biological influences (e.g., heredity, behavioral inhibition/temperament, autonomic reactivity, anxiety sensitivity) and environmental influences (e.g., insecure attachment style, overcontrolling/critical/anxious parenting style, peer and social problems, negative/stressful life events). Interactions among these factors are complex.
Course and Prognosis
Specific phobias may begin at any time during development. Phobic symptoms may follow association of a stimulus with an unexpected panic attack or a traumatic event. Most simple phobias remit spontaneously, but some persist. A recent longitudinal study showed that specific phobia may predict the development of many other psychiatric disorders, including other anxiety disorders, mood disorders, eating disorders, and pain disorders (Lieb et al. 2016). Youth with natural environment-type phobias (e.g., storms) fare more poorly and are more difficult to treat than youth with animal-type phobias (Ollendick et al. 2010). Social anxiety disorder, which tends to start in adolescence, can result in impaired social and academic/occupational functioning due to school avoidance, social withdrawal, substance abuse, and difficulty with dating and intimacy. In one large sample of youth, stressful life events were a significant factor in the development of social anxiety (Aune and Stiles 2009). The disorder tends to persist into adulthood and is associated with professional underachievement, depression, generalized anxiety symptoms, constrained social functioning, and significant functional impairment.
Evaluation and Differential Diagnosis
Parents are often unaware of phobic symptoms or social anxiety in their children, so the clinical interview with the child is especially important. However, younger children may not be able to describe avoidant behaviors, thus parent input regarding the child’s behaviors may be necessary. Younger children may express their phobic anxiety as crying, irritability, argumentativeness, tantrums, freezing, or clinging, rather than verbalizing it or explicitly avoiding the feared object or situation. Older youth may quietly avoid the feared stimulus or present with general irritability. A careful patient history aims to elucidate the feared stimulus, circumstances surrounding the development of the phobia, behavior in response to the phobic object or situation, anticipatory or avoidant behaviors, and any secondary gain. Observations of behavior may also be useful. A self-report questionnaire or clinician-administered measure designed for the specific presenting anxiety symptoms can be helpful to measure symptom severity or track treatment response, especially when symptoms are difficult to elicit by interview. Family assessment is also critical.
Differential diagnosis includes panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, learning disorders, mood and psychotic disorders, autism spectrum disorder, and eating disorders (if food or eating is avoided).
Clinicians often integrate several approaches to treat phobic disorders. Cognitive-behavioral treatments are the best studied and most efficient interventions for children with phobias. The positive effects of cognitive-behavioral therapy (CBT) appear to generalize, as seen in a study in which treatment of the targeted specific phobia led to improvement of comorbid specific phobias and other anxiety disorders (Ollendick et al. 2010). Effective behavioral treatment requires that the child have skills and the opportunities to manage the problem situation in alternative ways. The therapist evaluates the child’s skill set, teaches new skills when necessary, and works with the family (and school if appropriate) to eliminate inadvertent reinforcement of phobic behavior.
For specific phobias, CBT approaches developed for adults, such as systematic desensitization and exposure and response prevention (ERP) techniques, can be used in children, with strategies modified for developmental and cognitive levels. Systematic desensitization techniques (depending on specific phobia type) can include real life (“in vivo”) exposure, narrative stories (“emotive imagery”), modeling of coping behavior, and contingency management using shaping, positive reinforcement, and extinction techniques (King et al. 2005).
For treatment of social anxiety disorder, CBT programs incorporating psychoeducation, exposure techniques (practicing feared situations with gradual exposures using fear hierarchies), and social skills training are used with youth and caregivers. Published resources are available to provide instruction and worksheets for role plays of naturalistic exposures, social skill development such as meeting new people, and nonverbal communication skills for youth with social anxiety (Chorpita 2007). Supplemental CBT strategies to facilitate exposures include cognitive restructuring, active ignoring, time-out procedures, and use of positive reinforcement (reward contingency plans). Cognitive restructuring techniques aim to reduce cognitive, emotional, and behavioral symptoms by specifically addressing maladaptive, distorted, self-defeating, or unrealistic thought patterns. By challenging these negative cognitions (thought patterns) associated with anxiety-producing situations (e.g., school exams or evaluative social settings), youth learn to generate more positive and realistic thoughts, thus improving related feelings and reinforcing mastery, competence, assertiveness, and healthy problem-solving abilities.
Pharmacological studies often include subjects with mixed anxiety disorders. Randomized placebo-controlled trials (RCTs) support the use of the SSRIs fluoxetine, fluvoxamine, sertraline, or paroxetine (very rarely used in children) in the treatment of social anxiety disorder (generally with comorbidities of selective mutism, SAD, and/or GAD). Venlafaxine ER has also shown superior efficacy over placebo in the treatment of social anxiety disorder (March et al. 2007). Medication generally is reserved for cases in which severe symptoms interfere with psychotherapy or in which there is only a partial response to psychotherapy alone. A study comparing fluoxetine alone, psychotherapy (specifically Social Effectiveness Therapy for Children, or SET-C) alone, and placebo in the treatment of social anxiety disorder found that SET-C yielded superior results in reducing social distress, reducing avoidance, improving general functioning, improving social skills, and enhancing social competence (Beidel et al. 2007), underscoring the value of psychotherapy in treating social anxiety disorder. Benzodiazepines have potentially problematic adverse effects, are contraindicated in youth with a history of substance abuse, and have not shown efficacy in controlled trials; they are therefore not recommended other than possibly as an adjunctive short-term treatment with SSRIs in severe cases.
The U.S. Food and Drug Administration (FDA) has issued a “black box warning” for the use of any antidepressant medication, including SSRIs, in the pediatric population because of a small but statistically significant increased risk of suicidal thoughts (compared with subjects on placebo). Pharmacological studies of pediatric anxiety disorder did not find this increased risk (as opposed to pediatric depression, where this effect was seen), but careful monitoring is nonetheless essential when SSRIs are being used, with particular attention paid to mood, agitation, and suicidal thoughts or behaviors (see Chapter 17, “Psychopharmacology”).
DSM-5 (American Psychiatric Association 2013) unlinks the diagnoses of panic disorder and agoraphobia. Panic disorder and agoraphobia are relatively rare in children and somewhat more common in adolescents. Diagnostic criteria and physical symptom profile are the same as in adults. Family studies and retrospective reports note continuity between pediatric and adult presentations. Panic disorder requires recurrent unexpected abrupt surges of intense fear or discomfort that peaks rapidly (panic attack). Four or more of the 13 panic symptoms are required. They include both physiological and psychological features. In youth, cognitive immaturity may preclude some characteristic cognitions during an attack (fear of dying, going crazy, doing something uncontrolled). Panic attacks generally include shortness of breath, palpitations, chest pain, paresthesias, trembling, dizziness, tachycardia, sweating, and hyperventilation. Agoraphobia is described as intense fear or anxiety triggered by real or anticipated exposure to at least two different situations (e.g., using public transportation, being in open spaces, being in enclosed spaces, standing in line or in crowds, being outside of the home alone). For both diagnoses, the anxiety must be out of proportion to the actual danger or threat and impairment, and a 6-month duration of symptoms is required.
Prevalence of panic disorder is 1%–2% in children and 2%–4% in adolescents (Beesdo et al. 2009), with age at onset typically in late adolescence and early adulthood (American Psychiatric Association 2013). However, panic symptoms are much more common, with reported prevalence in adolescents of 13%–16% (Mattis and Ollendick 2002; Reed and Wittchen 1998). Panic disorder is more common in females than in males. Agoraphobia is even rarer in children, with a typical age at onset of 17 years. Less than 2% of adolescents and adults have a diagnosis of agoraphobia in any given year (American Psychiatric Association 2013).
Twin studies suggest genetic contributions. Modeling may also contribute. Offspring of parents with panic disorder are at high risk for anxiety disorders. A review of 24 studies concluded that cigarette smoking tends to both precede the onset of panic disorder and promote panic (Cosci et al. 2010). Individuals with panic disorder have an increased sensitivity to somatic sensations, referred to as interoceptive sensitivity (Domschke et al. 2010).
Course and Prognosis
The evolution of panic symptoms and the natural history of the disorder in children are not clear, but evidence supports chronicity (Biederman et al. 1997). Children with panic disorder and agoraphobia have high rates of other anxiety and mood disorders as well as attention-deficit/hyperactivity disorder (ADHD) (Biederman et al. 1997). Subclinical panic attacks, referred to as fear spells, may also predict later development of various psychiatric disorders (Asselmann et al. 2014). Prepubertal onset may signal greater severity (Vitiello et al. 1990). Youth with the somatic symptoms of panic disorder are likely to first seek the help of a pediatrician or an emergency room. Panic attacks can begin at the onset of or during an episode of major depression or SAD. Agoraphobia is typically chronic, though the type of triggering situation may vary (younger children are more likely to fear leaving the home alone).
Evaluation and Differential Diagnosis
Children can report current panic attacks, but parent report is helpful to verify duration and history. Self-monitoring techniques may be useful in children, as in adults. Panic disorder in children is likely underdiagnosed, with the symptoms often attributed to separation anxiety disorder, hyperventilation syndrome, or situational or “normal” anxiety. Panic attacks can be the anxiety manifestation in other anxiety disorders, so a careful history asking about triggers can help to differentiate panic disorder from other anxiety disorders. For unexplained somatic concerns, a careful (but not excessive) medical evaluation should be done to rule out medical conditions.
Education is essential for patients, families, and school staff (if symptoms interfere with school functioning). An RCT found a CBT-based treatment (Panic Control Treatment for Adolescents [PCT-A]) to be feasible and efficacious in a small sample of adolescents followed for up to 6 months posttreatment (Pincus et al. 2010). CBT strategies used with panic disorder are aimed at the reduction of the fear of sensations that trigger the anxiety response. They include relaxation techniques, cognitive strategies, and ERP, which can involve interoceptive exposure (gradual exposure to physical sensations by using exercises such as breath holding, running in place, or spinning to precipitate dizziness, shortness of breath, or sweating). SSRIs should be considered for panic symptoms that are persistent and/or impair functioning despite psychotherapeutic interventions. Although SSRIs have shown efficacy in adult panic disorder, there are no pediatric controlled trials. A pilot study suggests that fluoxetine and sertraline may be useful in treating panic symptoms (Renaud et al. 1999). In more severely affected youth with panic disorder, benzodiazepines may be considered for very cautious use, only short-term, given their many risks.
GENERALIZED ANXIETY DISORDER
Children with GAD have pervasive worries for at least 6 months about a variety of areas (Box 7–2). The DSM-5 criteria require only one accompanying symptom for children, whereas adults must have three.
Box 7–2 DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
- The individual finds it difficult to control the worry.
- The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item is required in children.
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
- Restlessness or feeling keyed up or on edge.
- The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
- The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).