Pediatric Anxiety Disorders
Gail A. Bernstein MD
Andrea M. Victor PhD
Introduction
Anxiety disorders is one of the most common categories of child and adolescent psychopathology. Although anxiety disorders are common during childhood and adolescence, many children do not gain access to services due to the difficulty in identifying internalizing symptoms. Therefore, it is critical for clinicians to develop an understanding of the presentation of anxiety disorders in children and adolescents and differentiate normal fear from anxiety disorders. Once anxiety disorders are identified, psychosocial treatments and medications have been shown to be beneficial in treating pediatric anxiety disorders.
History of Pediatric Anxiety Disorders
The primary anxiety disorders diagnosed during childhood and adolescence include separation anxiety disorder (SAD), generalized anxiety disorder (GAD), social phobia (SP), specific phobia, and panic disorder (PD). With the exception of SAD, these disorders are included in the “Anxiety Disorders” section of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) and are diagnosed across the lifespan. SAD is included in the “Disorders of Infancy, Childhood, and Adolescence” section of the DSM-IV-TR and requires that symptoms be present prior to 18 years of age.
GAD and SP are relatively new diagnoses in children and adolescents. Prior to the DSM-IV, GAD and SP were not diagnosed in youth. In the past, the diagnostic criteria for GAD required a minimum of 18 years of age. During that time, children with excessive anxiety were diagnosed with overanxious disorder (OAD), which was removed from the DSM-IV once the age requirement for GAD was discontinued. Similarly, youth who reported anxiety about or avoided engaging with unfamiliar people were typically diagnosed with avoidant disorder of childhood and adolescence. That diagnosis was removed from the DSM-IV, and those children are now commonly diagnosed with SP.
The essential DSM-IV-TR criteria of anxiety disorders included in this chapter are listed in Table 7-1. When evaluating anxiety disorders in youth, it is crucial that developmental considerations are taken into account. There are some essential differences between adult and youth criteria, which are outlined in the table.
Developmental Considerations
Anxiety is part of normal development; therefore, it is important to be cautious in distinguishing clinical anxiety from normal worry, which is estimated to occur in approximately 70% of children and adolescents. Normal fear is defined as an adaptive reaction to a real or imagined threat, whereas anxiety disorders are based on unrealistic and maladaptive reactions.
TABLE 7-1 Essential Symptoms of Anxiety Disorders and Unique Criteria for Youth | |||||||||||||||||||||||
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There is a developmental progression in common fears during childhood and adolescence. Infants and preschool-aged children typically have fears regarding concrete and specific situations, such as strangers, separation from caretakers, loud noises, and harm to self. Children more commonly endorse fears related to social, evaluative, and anticipatory experiences. With cognitive maturation, adolescents tend to demonstrate more global fears, which may include concerns about world affairs. It is necessary to understand the development of normal fears in order to assess anxiety disorders. Compared to normal fears, clinical anxiety is age and stage inappropriate, persistent, and impairing.
Epidemiology
Prevalence estimates of childhood anxiety disorders vary based on the type of epidemiologic study conducted. Higher prevalence rates result from studies with multiple assessment points, longer assessment intervals, and clinical samples. Epidemiologic studies that estimate the prevalence of any anxiety disorder during childhood show 3-month rates that range from 2% to 8% and 6-month rates that range from 5% to 18%. When estimating lifetime prevalence in retrospective studies with older adolescents and adults, the rates are even higher and range from 8% to 27%.
The prevalence rate of each anxiety disorder in youth has also been examined in epidemiologic studies. When considering nonclinical samples, there are some differences in prevalence rates and patterns of prevalence across pediatric anxiety disorders. SAD and specific phobia are more likely to be diagnosed during childhood versus adolescence. SAD has a prevalence rate of approximately 3% to 5%. Prevalence rates of specific phobia in youth range from 2% to 9%, with an average of approximately 5% across samples.
In contrast, GAD, SP, and PD are more likely to occur during adolescence compared to childhood. It is difficult to estimate the prevalence of GAD in children since it is a relatively new diagnosis in the pediatric age group. OAD, the previous diagnosis used for children with excessive worry, was estimated to occur in approximately 3% of youth. Lifetime prevalence rate of GAD in individuals who range from 15 to 54 years of age is estimated to be around 5%. SP is estimated to occur in approximately 5% of youth, with lifetime prevalence in adolescents estimated to be 16%. PD is relatively rare in youth, with a lifetime prevalence rate in adolescents estimated to be approximately 0.5%. Panic attacks seem to be significantly more common (18% prevalence rate) than a diagnosis of PD.
Etiology
There are many factors that have been identified in the etiology of childhood anxiety disorders. Etiology is often viewed within an integrated model that takes into account several factors and their relations to each other. These factors place children at a greater risk for developing an anxiety disorder, and the interplay of the factors tend to determine the presentation of the anxiety disorder.
Genetic Factors
Genetics
Genomic studies of childhood anxiety disorders have been initiated due to the belief that genetic factors impact the presentation of childhood anxiety disorders based on heritability estimates. Genetic studies provide evidence that specific genomic regions are likely related to the development of anxiety disorders; however, few studies have been completed for specific disorders, and the results are inconsistent. Linkage studies have located possible chromosomal
regions, and candidate gene studies have identified possible genes associated with anxiety disorders. These studies have focused primarily on PD, SP, specific phobia, and obsessivecompulsive disorder. It is difficult to identify specific genes related to anxiety disorders due to the complexity of the disorders. It is likely that many genes play a role in the presentation of anxiety disorders.
regions, and candidate gene studies have identified possible genes associated with anxiety disorders. These studies have focused primarily on PD, SP, specific phobia, and obsessivecompulsive disorder. It is difficult to identify specific genes related to anxiety disorders due to the complexity of the disorders. It is likely that many genes play a role in the presentation of anxiety disorders.
Temperament
Behavioral inhibition, a genetically based, temperamental trait, is often associated with anxiety. It refers to the child’s reaction to novel and unfamiliar stimuli. Children with behavioral inhibition have a tendency to respond to novel situations with restraint, distress, and avoidance. Studies have found that toddlers with behavioral inhibition compared to those without behavioral inhibition are more likely to develop an anxiety disorder during childhood and adolescence.
Attachment
Parent—child attachment is also related to the etiology of childhood anxiety disorders. Secure attachment with a primary caretaker may alleviate a child’s risk for an anxiety disorder. Research has shown that infants with an insecure attachment, particularly an anxious-resistant attachment, are more likely to develop an anxiety disorder by 17 years of age.
Parental Impact
Parental Anxiety
Children are more at risk of developing an anxiety disorder when a parent has an anxiety disorder. Studies have shown that children of parents with an anxiety disorder are two to five times more likely to have an anxiety disorder compared to children of parents with substance abuse and children of parents without a history of an anxiety disorder and/or substance abuse.
Parenting Style
There are three aspects of parenting style associated with childhood anxiety: low acceptance, excessive control, and modeling of anxiety. These are conceptualized as moderators of childhood anxiety and not direct predictors. Acceptance is characterized by warmth and responsiveness in parent—child interactions. Parents who are low on acceptance tend to demonstrate more criticism and rejection. Control refers to the degree parents regulate their children’s activities, thoughts, and feelings. When parents use excessive control, children do not learn mastery of their environment. Finally, parents who exhibit anxious behaviors (i.e., avoidance, catastrophic thinking, and poor problem solving) often impart negativity and poor coping skills to their children.
Clinical Syndromes
Separation Anxiety Disorder
Clinical Presentation
Separation anxiety from primary caregivers is a developmentally normal response in infants and young children up to 30 months of age. It typically decreases between 3 and 5 years of age as children’s cognitive maturation allows them to understand that separation from a caregiver is temporary. SAD is more common in children than in adolescents and typically has an age of onset between 7 and 9 years.
The key theme of SAD is extreme anxiety and distress about separation from primary attachment figures (e.g., parents, siblings, and grandparents). Children with SAD fear that harm will come to them or their attachment figures when they are separated. Other symptoms of SAD are listed in Table 7-1. To meet DSM-IV-TR criteria for SAD, the symptoms must be more intense and impairing than expected for the child’s developmental level, be present for a minimum of 4 weeks, and have an onset before age 18. A distinguishing feature of SAD is that the anxiety abates when the child is with his or her parent, which is not the case with GAD or SP.
Clinical Course
The course of SAD may be short lived or chronic and persistent. A study prospectively followed children in an anxiety disorders clinic for 3 to 4 years and reported that SAD had the highest remission rate (96%). Another longitudinal study was completed with 3-year-old children with clinical, subclinical, or nonclinical level of separation anxiety. The children were evaluated at baseline and 3.5 years later. At baseline, children with clinical SAD were more likely to have comorbid diagnoses, greater severity of anxiety, somatic complaints, internalizing symptoms, and parents with internalizing symptoms. Many children with SAD did not have a stable diagnosis, with their symptoms moving toward subclinical or nonclinical status at follow-up. Predictors of persistent SAD were family and parent variables (e.g., inconsistency in limit setting).
A community-based sample of 8- to 17-year-old twins with SAD was followed for 18 months. Only 20% had persistence of the SAD diagnosis at 18-month follow-up. Baseline factors predicting persistence of SAD were oppositional defiant disorder, impairing symptoms of attentiondeficit hyperactivity disorder (ADHD), and maternal marital dissatisfaction. Youth with persistent SAD were significantly more likely to develop a depressive disorder at follow-up.
Participants from the Oregon Adolescent Depression Project were assessed twice as teenagers and twice as adults. Many of the teenagers with a history of SAD developed new disorders during the follow-up period. The most common outcomes for teenagers with a history of SAD were depression in 75% and PD in 25%. This study suggests a specific link between SAD in childhood and PD in adulthood; however, several other studies suggest that SAD is a risk factor for a number of different anxiety disorders in adulthood, not only PD.
Comorbidity
Common comorbid conditions include GAD, SP, specific phobia, and ADHD. Children with SAD were found to have a greater number of comorbid diagnoses compared to those with GAD or SP. However, children with SAD were least likely to have a comorbid mood disorder.
Generalized Anxiety Disorder
Clinical Presentation
GAD presents as children with multiple areas of worry. These worries are excessive, difficult to control, and impede the youth’s daily functioning. The worries must have at least one associated symptom (i.e., restlessness, easily tired, difficulty concentrating, irritability, muscle tension, and/or sleep difficulties).
Since all children worry, it is critical to differentiate children with normal worry from those with GAD. Children with GAD endorse a higher number of worries and more intense worries compared to children with other anxiety disorders and healthy control children. The content of worry in children with GAD is also important to consider. Worry about health of self and of significant others has been shown to be the most predictive of a GAD diagnosis. Other common worries include school performance, appearance, and family issues (e.g., divorce and finances). The presence of associated symptoms (e.g., restlessness and difficulty concentrating) also differentiates children with GAD from other children. The number of associated symptoms seems to increase with age. Studies showed that children with GAD endorsed an average of 3.4
associated symptoms, and found that restlessness was the most common and muscle tension was the least common.
associated symptoms, and found that restlessness was the most common and muscle tension was the least common.
Clinical Course
GAD in youth tends to follow a chronic course with waxing and waning of symptoms and a greater degree of comorbid psychopathology compared to adult-onset GAD; therefore, early identification is beneficial. A comorbid diagnosis of depression in children with GAD usually results in a poorer prognosis, increased symptom severity, and lengthier duration of symptoms.
Since GAD and depression often co-occur and there is significant overlap in symptom constellations, there is a question as to whether these should be considered two distinct disorders. There are conflicting arguments among researchers regarding the relation between GAD and major depressive disorder (MDD). Some researchers propose that GAD is a subsyndrome to MDD because it typically occurs before the onset of MDD. This is referred to as “sequential comorbidity.” In contrast, others propose that GAD and MDD typically do not occur in a predictable order. This is referred to as “cumulative comorbidity.” Studies support both sequential and cumulative comorbidity. These concepts are continuing to be examined to develop a better understanding of the association between GAD and MDD.
Comorbidity
The majority of children with GAD have a comorbid diagnosis. The most common comorbid diagnosis is another anxiety disorder. Depression is also a common comorbid diagnosis in clinical samples. Only 4% of children with GAD from a nonclinical sample had a comorbid depressive disorder, whereas 66% of children with GAD from a clinical sample had a comorbid depressive disorder.
Social Phobia
Clinical Presentation
SP typically presents in children and adolescents as significant anxiety of social and/or performance situations due to fear they will act in an embarrassing manner. Common social situations that are feared by children with SP include speaking in class, talking on the phone, and interacting with peers. Feared social situations provoke an anxious response and are avoided or endured with marked distress.
There is increasing evidence that selective mutism, a consistent failure to speak in specific social situations (e.g., school and playdates), is related to SP. There is debate as to whether selective mutism should be conceptualized as a subtype of SP due to the significant overlap between the cardinal symptoms of the two disorders. Both disorders include a marked fear of social and/or performance situations, avoidance of those feared situations, and often a lack of anxiety when the child is in the home environment.
The argument to include selective mutism as a subtype of SP is based primarily on three reasons. First, children with selective mutism often endorse high rates of social anxiety, shyness, and avoidance of social situations. Second, children who are diagnosed with selective mutism commonly continue to struggle with social anxiety throughout adolescence and adulthood even after the mutism is gone. Third, children with selective mutism have relatives with high rates of anxiety disorders. Although there is evidence to support selective mutism as a subtype of SP, there is concern that there is more to the etiology of selective mutism than just social anxiety. Children with selective mutism have higher rates of language impairments and problematic interactions with peers, which are not included in the diagnostic criteria for SP.
There are some differences in presentation of SP in children and adolescents compared to adults. It is necessary to assess the youth’s ability to engage in age-appropriate social relationships, which is required for a diagnosis of SP. Furthermore, the child’s social anxiety must
occur during interactions with peers, not only with adults. Children do not need to recognize that their social fears are unreasonable, as is required to make a diagnosis in adults.
occur during interactions with peers, not only with adults. Children do not need to recognize that their social fears are unreasonable, as is required to make a diagnosis in adults.
Clinical Course
The onset of SP typically occurs during early adolescence. This is likely due to the youth’s increased awareness of others’ perceptions. Youth with SP report increased overall anxiety, depression, and loneliness. Children with SP also have low social acceptance and difficulty with social skills, which may be related to their avoidance of social situations. An increase in severity of SP symptoms in children seems to be related to an increase in deficits in social skills and leadership skills, attention difficulties, and learning problems based on teacher report.
The occurrence of SP during childhood or adolescence is a risk factor for the development of psychiatric disorders in adulthood, particularly GAD and depression, as well as ongoing SP. SP is a unique risk factor for the later onset of cannabis and alcohol dependence in adulthood. Due to the chronic course of SP, it is commonly associated with social, educational, and occupational impairment.
Comorbidity
Children with SP often have comorbid psychiatric disorders. In a recent study, all 45 children with SP in a nonclinical sample had at least one comorbid disorder, with 84% meeting criteria for at least one other anxiety disorder (73% had GAD, 51% had SAD, and 36% had specific phobia). There is an increase in comorbid depression and substance abuse in adolescents with SP compared to children with SP.
Specific Phobia
Clinical Presentation
Specific phobia refers to a persistent and unreasonable fear of a specific object or situation that leads to distress and/or avoidance. The fear is so intense that it causes interference in the child’s daily functioning. There are five main types of specific phobias: animal, natural environment, blood-injection-injury, situational, and other. It is common for a child to have more than one type of specific phobia. A fear is typically classified as a specific phobia when it is excessive, persistent over time, and not specific to the child’s age and/or developmental level.
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