Anxiety Disorders of Infancy, Childhood, and Adolescence

There are four categories of anxiety disorders in children. The first is obsessive-compulsive disorder (OCD). OCD is characterized by the presence of recurrent intrusive thoughts associated with anxiety or tension and/or repetitive purposeful mental or physical actions aimed at reducing fears and tensions caused by obsessions. It has become increasingly clear that the majority of cases of OCD begin in childhood or adolescence. The clinical presentation of OCD in childhood and adolescence is similar to that in adults, and the only alteration in diagnostic criteria in the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) for children is that they do not necessarily demonstrate awareness that their thoughts or behaviors are unreasonable.

The second category is posttraumatic stress disorder (PTSD). PTSD is characterized by a set of symptoms such as reexperiencing symptoms, distressing recollections, persistent avoidance, and hyperarousal in response to exposure to one or more traumatic events. Many children and adolescents are exposed to traumatic events ranging from direct experiences with physical or sexual abuse, domestic violence, motor vehicle accidents, severe medical illnesses or natural or human-created disasters, leading to full PTSD in some and at least some PTSD symptoms in many others. Although the presence of posttraumatic stress symptoms has been described among adults for more than a century, it was first officially recognized as a psychiatric disorder in 1980 with the publication of the DSM-III. Recognition of its frequent emergence in children and adolescence has broadened over the past decade.

The third category includes separation anxiety disorder, generalized anxiety disorder (GAD), and social phobia. Separation anxiety disorder is diagnosed when developmentally inappropriate and excessive anxiety emerges related to separation from the major attachment figure. GAD is characterized by chronic generalized anxiety not limited to any particular idea, object, or event.

The fourth category is selective mutism. Selective mutism is characterized in a child by persistent failure to speak in one or more specific social situations, most typically including the school setting. The most recent conceptualization of selective mutism highlights the relationship between underlying social anxiety and the resulting failure to speak. Most children with the disorder are completely silent during the stressful situations, but some may verbalize almost inaudibly single-syllable words. Children with selective mutism are fully capable of speaking competently when not in a socially anxiety-producing situation.

Students should study the questions and answers below for a useful review of these disorders.

Helpful Hints

Students should be able to define the following terms.

adoption studies
age of onset
anticipatory
aphonia
asthma
attention-deficit/hyperactivity disorder (ADHD)
β-adrenergic receptor antagonists
cannabis-induced
central noradrenergic system
cognitive-behavioral
comorbid disorders
EEG
exposure therapy
family studies
free-floating
genetics
impulse control
kleptomania
life events
neurochemical
neuroimaging
panic disorder
performance
psychotherapy
rating scales
religious ritual
self-cutting
separation
separation anxiety disorder
serotoninergic system
situational
startle reflex
stranger
striatum
substance abuse
temperament
thalamus
Tourette’s disorder
trait

Questions

Directions

Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.

49.1 Which of the following is not a true statement about the genetics of OCD?

A. There is an increased risk of OCD in first degree relatives.

B. Subclinical syndromes occur in family pedigrees.

C. OCD is related to Tourette’s disorder.

D. There is a linkage to chromosome 21.

E. Tics are highly correlated to OCD.

View Answer

49.1 The answer is D

OCD is a heterogeneous disorder that has been recognized for decades to run in families. Family studies have documented an increased risk of at least fourfold in the first-degree relatives of early-onset OCD. In addition, the presence of subclinical symptom constellations in family members appears to breed true. Molecular genetic studies have suggested linkage to regions of chromosomes 2 and 9 (not 21) in certain pedigrees with multiple members exhibiting early-onset OCD. Candidate gene studies have been inconclusive thus far. Family studies have pointed to a relationship between OCD and tic disorders such as Tourette’s disorder. OCD and tic disorders are believed to share susceptibility factors. The concept of a broader “obsessive-compulsive spectrum” including eating disorders, and somatoform disorders may account for the expression of repetitive and stereotyped symptoms.

49.2 According to clinical trials, child OCD patients taking clomipramine (Anafranil) showed significant improvement after how many weeks?

A. 4 to 6 weeks

B. 6 to 8 weeks

C. 8 to 10 weeks

D. 10 to 12 weeks

E. 12 to 14 weeks

View Answer

49.2 The answer is C

Clomipramine (Anafranil), a tricyclic antidepressant (TCA), is the most researched medication in the treatment of children with OCD. In a double-blind, 8-week, placebo-controlled study, 60 percent of pediatric patients showed significant improvement. Patients treated with clomipramine reported a 37 percent mean reduction in OCD symptoms compared with 8 percent for the placebo group (with an effect size approaching 1.0). In another 10-week controlled trial, a significant difference was found between clomipramine and placebo, with 75 percent of pediatric patients showing at least moderate improvement. Other research found that clomipramine was superior to the noradrenergic reuptake inhibiting TCA desipramine (Norpramin). This crossover trial found that 64 percent of patients who initially received clomipramine during their first treatment showed relapse of OCD symptoms during desipramine treatment.

49.3 Developmentally appropriate separation anxiety usually begins around what age?

A. 3 months

B. 4 months

C. 5 months

D. 6 months

E. 7 months

View Answer

49.3 The answer is D

Developmentally appropriate separation anxiety typically presents around age 6 months and declines between ages 2 and 3 years. Children with separation anxiety disorder have either persistent and worsening or new onset separation anxiety in the school-aged years (i.e., ages 6 to 12 years).

49.4 Separation anxiety in children is characterized by

A. fears that a loved one will be hurt

B. fears about getting lost

C. irritability

D. animal and monster phobias

E. all of the above

View Answer

49.4 The answer is E (all)

Morbid fears, preoccupations, and ruminations are characteristic of separation anxiety in children. Children become fearful that someone close to them will be hurt or that something terrible will happen to them when they are away from important caring figures. Many children worry that accidents or illness will befall their parents or themselves. Fears about getting lost

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