Anxiety disorders in childhood and adolescence
Daniel S. Pine
Introduction
The term ‘fear’ refers to the brain state evoked by dangerous stimuli that are avoided because they are capable of harming the organism. The term ‘anxiety’, in contrast, refers to the brain state evoked by ‘threats’, stimuli that signal the possibility of danger at some point in the near future. Fear and anxiety represent adaptive responses to overt dangers and threats, in that these responses typically reduce the potential for harm to the organisms. Anxiety disorders represent conditions where the level of fear is maladaptive either because it leads to clinically significant distress or impairment in function. These effects can result from the production of an anxiety response in a situation not perceived as dangerous by healthy people or by the production of an extreme anxiety response in a situation that healthy people would find mildly anxiety provoking.
The current chapter summarizes recent research on paediatric anxiety disorders. A focus on developmental aspects of anxiety is important since most clinically impairing forms of anxiety typically begin during childhood.(1) Moreover, childhood anxiety disorders show associations with a range of adult psychopathologies beyond anxiety, including most prominently various mood disorders. This fact has stimulated considerable debate concerning the degree to which childhood anxiety disorders reflect early manifestations of adult anxiety disorders. Separation anxiety disorder (SAD) represents the only specific anxiety disorder that primarily occurs in children and adolescents but not adults. Two other disorders frequently co-occur with SAD, social phobia (SOPH), and generalized anxiety disorder (GAD). The current chapter focuses specifically on these three conditions. The chapter also reviews in somewhat less detail data for specific phobia (SPH), a typically minimally impairing condition, and panic disorder (PD), a condition that occurs primarily in adults.(1) Other chapters review material for conditions that frequently co-occur with these five anxiety disorders. This includes major depression (see Chapter 9.2.7), obsessive-compulsive disorder (Chapter 9.2.8), and trauma-related disorders (Chapters 9.3.2). Material on SAD, SOPH, GAD, SPH,
and PD are reviewed in three sections. The first, most detailed, section reviews clinical features of these disorders, including typical presentations and diagnosis. The second somewhat briefer section reviews pathophysiology, and the final section briefly reviews therapeutics.
and PD are reviewed in three sections. The first, most detailed, section reviews clinical features of these disorders, including typical presentations and diagnosis. The second somewhat briefer section reviews pathophysiology, and the final section briefly reviews therapeutics.
Clinical features
Clinical presentation
Children presenting with symptoms of anxiety typically manifest signs of various disorders. In fact, in the clinical setting, presentation with a ‘pure’ form of anxiety is relatively rare. This suggests that current classifications group children into categories that are unlikely to represent distinct pathophysiologies. Nevertheless, while the current nosology is likely to change as understandings of pathophysiology advance, current classification schemes remain quite useful in that they facilitate communication among individuals working with a child and allow clinicians to draw on research in therapeutics using a common diagnostic system. The current section describes clinical presentation of five specific anxiety disorders, as defined in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV). These definitions are similar to those used in the 10th edition of the International Classification of Disease (ICD-10), although ICD-10 provides single diagnosis for children with multiple anxiety disorders, whereas and DSM-IV provides multiple diagnoses.
(a) Separation anxiety disorder
The key feature of SAD involves presentation of anxiety related to fear that harm will befall an attachment figure. In severe forms, SAD typically presents with avoidance of situations, such as school, where separation is required. The term ‘school phobia’ had been used on occasion for these presentations, but current approaches no longer use this term. Symptoms of SAD often are severe at night, leading many children to refuse to sleep alone or at friends’ homes. Considerable research examines the relationship between childhood SAD and adult panic disorder.
(b) Social phobia
The key features of SOPH involve intense fear or anxiety in situations where the individual is scrutinized. This presents either as extreme form of pervasive shyness or as extreme fear in particular social situations, such as during class presentations. SOPH can also be classified as a ‘generalized subtype’, indicating that most social situations are feared. The condition can markedly interfere with function by leading children to avoid important academic exercises that must be performed in social settings or by markedly impacting on social development. This effect on social relationships has led to some controversy concerning the boundaries between SOPH and pervasive developmental disorders (PDD). Classically, this distinction can be made based on the presence of language dysfunction and stereotypic behaviour in PDD but not SOPH. Considerable research examines the relationship between late-childhood SOPH and early-childhood temperament.
(c) Generalized anxiety disorder
The key feature of GAD involves a pervasive sense of worry about various events or circumstances. For example, children with GAD frequently worry about their competence, as might manifest on school or athletic performances. These worries are associated with other symptoms, such as muscle tension or other somatic complaints, irritability, and trouble sleeping. Because children with SAD and SOPH also present with worry, clinicians face difficulties when attempting to determine if worries reflect aspects of these disorders or another problem. GAD is diagnosed only when worries cannot be accounted for by another diagnosis. Considerable research examines the relationship between GAD and major depressive disorder (MDD).
(d) Specific phobia
The key feature of SPH involves fear of a specific stimulus or object. SPH can manifest to a range of objects, such as potentially dangerous animals or natural scenarios, and SPH can be categorized into one of five types, based on the content of the fear. Children rarely present for clinical care when they suffer from SPH in the absence of another anxiety disorder, despite the fact that SPH does present relatively commonly in pure forms in the community. This suggests that SPH typically is associated with relatively mild degrees of distress and impairment, unless SPH is associated with another anxiety disorder.
(e) Panic disorder
The key feature of PD involves spontaneous panic attacks. The term ‘panic attack’ refers to crescendo paroxysms of severe anxiety that occur suddenly and are associated with somatic and cognitive sensations, such as rapid heart beat, shortness of breath, and a strong desire to flee. Panic attacks occur in many situations and with various clinical syndromes. The key feature of PD is that at least some of these attacks occur in the absence of any cue or trigger. As such, the patient cannot attribute the attack to fear of any specific circumstance. PD virtually never occurs prior to puberty, and the disorder is also very rare before adulthood.
Assessment
The assessment for anxiety involves input from multiple sources. Clearly obtaining information directly from the patient is vital. Children with anxiety disorders may be reluctant to report the precise nature of their fears. As a result, adults may be unaware of vital symptoms. On the other hand, children also often show reluctance to acknowledge their anxiety, either because they are unaware of their degree of incapacitation or because they are highly embarrassed about their symptoms. In this instance, adults provide vital information concerning specific objects or situations that might be feared by children or adolescents.
Various forms of standardized assessment are available for paediatric anxiety.(2) This includes rating scales that can be directly completed by parents, teachers, or children, as well as scales that are completed by clinicians based on their interview of the child and parent. Moreover, standardized observational batteries typically are used for the assessment of temperament, in very young children, that relate to anxiety disorders in older children. Temperament also can be measured by parent or self-report.(3) In general, while high scores on various rating scales does provide some indication regarding the presence of an anxiety disorder, structured psychiatric interviews, completed by a trained clinician, represents the gold standard for arriving at a diagnosis.
Prevalence and demographics
As a group, paediatric anxiety disorders probably represent the most common form of developmental psychopathology. It is
difficult to provide precise data concerning their overall prevalence, as the rate of anxiety disorders is highly variable across studies, most likely due to variations in assessment. Rates of anxiety disorders are unusually sensitive to even subtle changes in assessments of impairment.(4) In general, overall lifetime rates of paediatric anxiety probably fall in the 10-20 per cent range.(5) Rates of individual disorders vary with age. Thus, SAD represents the most common condition, with prevalence typically in the 5 per cent range, before puberty, whereas GAD and SOPH become more prevalent during adolescence, again with rates in the 5 per cent range. Rates of SPH are highly variable, depending on the stringency of impairment criteria, with some estimates surpassing 20 per cent. As noted above, PD is very rare before late adolescence.
difficult to provide precise data concerning their overall prevalence, as the rate of anxiety disorders is highly variable across studies, most likely due to variations in assessment. Rates of anxiety disorders are unusually sensitive to even subtle changes in assessments of impairment.(4) In general, overall lifetime rates of paediatric anxiety probably fall in the 10-20 per cent range.(5) Rates of individual disorders vary with age. Thus, SAD represents the most common condition, with prevalence typically in the 5 per cent range, before puberty, whereas GAD and SOPH become more prevalent during adolescence, again with rates in the 5 per cent range. Rates of SPH are highly variable, depending on the stringency of impairment criteria, with some estimates surpassing 20 per cent. As noted above, PD is very rare before late adolescence.
In terms of demography, anxiety disorders show a strong female predominance. This gender difference manifests for all of the conditions examined here, and, unlike data for MDD, it emerges before puberty. While the overall rate of anxiety disorders changes relatively little from childhood to adolescence, the nature of disorders does change. Thus, SAD is most common in young children, whereas SOPH is most common in adolescence. Data concerning associations with social class appear somewhat mixed. While some inconsistent reports note higher rates among individuals in the relatively lower social strata, the data appear most consistent for SPH, with weaker or absent associations in other conditions.(1) Consistent with weak relationships, recent work suggests that abrupt changes in family economics do not lead to changes in rates of anxiety disorders, despite strong associations with changing rates of other disorders.(6)
Comorbidity
Data concerning comorbidity reveal distinct trends in the clinic relative to the community, most likely due to the effects of referral biases on data from the clinic. Thus, in the clinic, paediatric anxiety disorders have been linked to virtually every form of psychopathology. This includes mood disorders, behaviour disorders, attention deficit hyperactivity disorder, and substance use disorders. In the community, however, associations appear particularly strong with a more restricted group of conditions. The most common comorbidity represents associations with other anxiety disorders, with odds ratios typically appearing in the three-to-five range.(1) Associations between SOPH and GAD appear particularly strong in this work. Comorbidity with mood disorder, particularly MDD, is only slightly weaker than comorbidity among the anxiety disorders.(7) Other forms of psychopathology show far weaker associations.
Clinical course
Paediatric anxiety disorders predict an increased risk for a range of adverse psychiatric outcomes in adults. This includes most prominently risk for adult anxiety disorders and MDD.(1,8) In general, children and adolescent with one or another anxiety disorder face a two- to five-fold increased risk for adult anxiety or MDD. These relationships reflect the fact that most adults with various forms of mood or anxiety disorder show the initial signs of their problem during childhood or adolescence, manifest as a paediatric anxiety disorder. However, the overall magnitude of these longitudinal relationships between paediatric anxiety and any form of adult psychopathology appears somewhat weaker than longitudinal relationships for other developmental psychopathologies, such as the behaviour disorders.(9)
Relatively few studies consider the long-term outcome of the specific paediatric anxiety disorders. In the few studies that do examine this issue, the overall weight of the evidence suggests that risk for poor outcome is similar among all paediatric anxiety disorders.(5) However, some inconsistent data do note specific associations among individual child and adult disorders. For example, some evidence documents a particularly strong association between paediatric GAD and adult MDD,(1) though studies following adolescents into their 30s suggest a comparable risk for MDD in adolescent SOPH.(8) Similarly, some studies note an association between childhood SAD and adult PD, but the overall weight of the evidence does not provide strong support for this link.(10) Finally, some inconsistent evidence also suggests that the outcome of paediatric SPH appears relatively good, as compared with other anxiety disorders.
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