Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V.
Journal: 2009/November - Psychiatric Clinics of North America
ISSN: 1558-3147
Abstract:
This review summarizes findings on the epidemiology and etiology of anxiety disorders among children and adolescents including separation anxiety disorder, specific phobia, social phobia, agoraphobia, panic disorder, and generalized anxiety disorder, also highlighting critical aspects of diagnosis, assessment, and treatment. Childhood and adolescence is the core risk phase for the development of anxiety symptoms and syndromes, ranging from transient mild symptoms to full-blown anxiety disorders. This article critically reviews epidemiological evidence covering prevalence, incidence, course, and risk factors. The core challenge in this age span is the derivation of developmentally more sensitive assessment methods. Identification of characteristics that could serve as solid predictors for onset, course, and outcome will require prospective designs that assess a wide range of putative vulnerability and risk factors. This type of information is important for improved early recognition and differential diagnosis as well as prevention and treatment in this age span.
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Psychiatr Clin North Am 32(3): 483-524

Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V

ANXIETYAND ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS AND ITS ASSESSMENT

Childhood and adolescence is the core risk phase for the development of symptoms and syndromes of anxiety that may range from transient mild symptoms to full-blown anxiety disorders. Challenges from a research perspective include its reliable and clinically valid assessment to determine its prevalence and patterns of incidence, and the longitudinal characterization of its natural course to better understand what characteristics are solid predictors for more malignant courses as well as which are likely to be associated with benign patterns of course and outcome. This type of information is particularly needed from a clinical perspective to inform about improved early recognition and differential diagnosis as well as preventions and treatment in this age span.

Anxiety refers to the brain response to danger, stimuli that an organism will actively attempt to avoid. This brain response is a basic emotion already present in infancy and childhood, with expressions falling on a continuum from mild to severe. Anxiety is not typically pathological as it is adaptive in many scenarios when it facilitates avoidance of danger. Strong cross-species parallels—both in organisms’ responses to danger and in the underlying brain circuitry engaged by threats—likely reflect these adaptive aspects of anxiety.1 One frequent and established conceptualization is that anxiety becomes maladaptive when it interferes with functioning, for example when associated with avoidance behavior, most likely to occur when anxiety becomes overly frequent, severe, and persistent.2 Thus, pathological anxiety at any age can be characterized by persisting or extensive degrees of anxiety and avoidance associated with subjective distress or impairment. The differentiation between normal and pathological anxiety, however, can be particularly difficult in children because children manifest many fears and anxieties as part of typical development34 (Table 1). Although these phenomena might be acutely distressing, they occur in most children and are typically transient. For example, separation anxiety normatively occurs at 12 to 18 months, fears of thunder or lightning at 2 to 4 years, and so forth. Thus, given that such anxiety occurs in most children and typically does not persist, distress, in and of itself, represents an inadequate criterion for distinguishing among normal and pathological anxiety states in children. This problem creates unique challenges when trying to distinguish among normal, subclinical, and pathological anxiety states in children. Other challenges in the assessment of childhood fears and anxiety are that children at younger ages may have difficulties in communicating cognition, emotions, and avoidance, as well as the associated distress and impairments, to the diagnostician5 because they might lack the cognitive capabilities used to communicate information vital to the application of the diagnostic classification system. Thus, developmental differences (eg, cognition, language skills, emotional understanding) must be carefully considered when assessing anxiety in young people to make a diagnostic decision.6

Table 1

Normative anxiety and fears in childhood and adolescence

AgeDevelopment Conditioned Periods of Fear and AnxietyPsychopathological Relevant SymptomsCorresponding DSM-IV Anxiety Disorder
Early infancyWithin first weeksFear of loss, eg, physical contact to caregivers
0–6 monthsSalient sensoric stimuli

Late infancy6–8 monthsShyness/anxiety with strangerSeparation anxiety disorder

Toddlerhood12–18 monthsSeparation anxietySleep disturbances, nocturnal panic attacks, oppositional deviant behaviorSeparation anxiety disorder, panic attacks
2–3 yearsFears of thunder and lightening, fire, water, darkness, nightmaresCrying, clinging, withdrawal, freezing, eloping seek for security and physical contact, avoidance of salient stimuli (eg, turning the light on), pavor nocturnus, enuresisSpecific phobias (environmental subtype), panic disorder
Fears of animalsSpecific phobias (animal subtype)

Early childhood4–5 yearsFear of death or dead peopleGeneralized anxiety disorder, panic attacks

Primary/elementary school age5–7 yearsFear of specific objects (animals, monsters, ghosts)Specific phobias
Fear of germs or getting a serious illnessObsessive compulsive disorder
Fear of natural disasters, fear of traumatic events (eg, getting burned, being hit by a car or truck)Specific phobias (environmental subtype), acute stress disorder, posttraumatic stress disorder, generalized anxiety disorder
School anxiety, performance anxietyWithdrawal, timidity, extreme shyness to unfamiliar people and peers, feelings of shameSocial anxiety disorder

Adolescence12–18 yearsRejection from peersFear of negative evaluationSocial anxiety disorder

Data from Morris RJ, Kratochwill TR. Childhood fears and phobias. In: Kratochwill TR, Morris RJ, editors. The practice of child therapy. 2nd ed. New York: Pergamon; 1991. p. 76–114; and Muris P, Merckelbach H, Mayer B, et al. Common fears and their relationship to anxiety disorders symptomatology in normal children. Pers Individ Diff 1998;24(4):575–8.

Anxiety disorders are described and classified in diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM, currently version IV-TR, American Psychiatric Association)2 or the International Classification of Diseases (ICD, currently version 10, World Health Organization)7 (Table 2). Across these systems, many anxiety disorders share common clinical features such as extensive anxiety, physiological anxiety symptoms, behavioral disturbances such as extreme avoidance of feared objects, and associated distress or impairment. Nonetheless, differences exist and it should be noted that narrowly categorized anxiety disorders such as panic disorder, agoraphobia, and subtypes of specific phobias also exhibit a substantial degree of phenotypical diversity or heterogeneity.

Table 2

Classification of anxiety disorders according to ICD-10 and DSM-IV

ICD-10DSM-IV

Neurotic, somatoform, and stress-related disordersAnxiety disordersDifferent criteria in children (vs adults)
Information on childhood anxieties as highlighted in DSM text portion
F40Phobic disorder

F40.0Agoraphobia

F40.00Agoraphobia without panic disorder300.22Agoraphobia without history of panic disorder

F40.01Agoraphobia with panic disorder300.21Panic disorder with agoraphobia

F40.1Social phobia300.23Social phobia
  • A

    In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the social anxiety must occur in peer settings, not just in interactions with adults

  • B

    In children, the anxiety may be expressed by crying, tantrums, freezing, shrinking from social situations with unfamiliar people

  • C

    In children, the C criterion (recognizes that fear is excessive/unreasonable) may be absent.

  • F

    In individuals < 18 years, duration is at least 6 months

    Fears of being embarrassed in social situations are common, but usually the degree of distress or impairment is insufficient to warrant a diagnosis Transient social anxiety or avoidance is especially common in childhood and adolescence (eg, an adolescent girl may avoid eating in front of boys for a short time, then resume usual behavior). Unlike adults, children may not have the option of avoiding feared situations altogether, and may be unable to identify the nature of their anxiety.


F40.2Specific (isolated) phobia300.29Specific phobia
  • B

    In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging

  • C

    In children, the C criterion (recognizes that fear is excessive/unreasonable) may be absent

  • F

    In individuals < 18 years, duration is at least 6 months

    Fear of animals and other objects in the natural environment are particularly common and are usually transitory in childhood. A diagnosis is not warranted unless the fears lead to clinically significant impairment (eg, unwillingness to got to school for fear of encountering a dog on the street)


F40.8Other

F40.9Not specified300.00Anxiety disorders NOS

F41Other anxiety disorders

F41.0Panic disorder (episodic paroxysmal anxiety)300.01Panic disorder without agoraphobia

F41.1Generalized anxiety disorder300.02Generalized anxiety disorder
  • C

    In children, 1 instead of 3 out of 6 symptoms is required

    In children and adolescents the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events such as earthquakes or nuclear war. Children may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They are typically overzealous in seeking approval and require excessive reassurance about their performance and their worries. The disorder may be overdiagnosed in children, thus a thorough evaluation of presence of other childhood anxiety disorders should be done to determine whether the worries may be better explained by one of these disorders.


F41.2Mixed anxiety and depressive disorder

F41.3Other mixed anxiety disorders

F41.8Other

F41.9Not specified300.00Anxiety disorders NOS

F42Obsessive compulsive disorder300.3Obsessive-compulsive disorder
  • B

    criterion does not apply to children

    Presentations in children are generally similar to those in adulthood. Washing, checking, and ordering rituals are particularly common in children. Children generally do not request help, and the symptoms may not be ego-dystonic. More often the problem is identified by parents. Gradual declines in schoolwork secondary to impaired ability to concentrate have been reported. Like adults, children are more prone to engage in rituals than in front of peers, teachers, or strangers. For a small subset of children, the disorder may be associated with Group A beta-hemolytic streptococcal infection. This form is characterized by prepubertal onset, associated neurological abnormalities, and an abrupt onset of symptoms or an episodic course in which exacerbations are temporally related to the streptococcal infections.


F42.0Predominantly obsessional thoughts or ruminations
F42.1Predominantly compulsive acts (obsessional rituals)
F42.2Mixed obsessional thoughts and acts

F42.8Other

F42.9Not specified

F43Reaction to severe stress and adjustment disorder

F43.0Acute stress reaction308.3Acute stress disorder

F43.1Posttraumatic stress disorder309.81Posttraumatic stress disorder
  • A(2)

    In children, the criterion may be expressed by disorganized or agitated behavior

  • B(1)

    In young children, repetitive play may occur in which themes or aspects of the trauma are expressed

  • B(2)

    In children, there may be frightening dreams without recognizable content

  • B(3)

    In young children, trauma-specific reenactment may occur

    Because it may be difficult for children to report diminished interest in significant activities and constrictions of affect, these symptoms should be carefully evaluated with reports from parents, teachers, and other observers. In children, the sense of foreshortened future may be evidenced by the belief that life will be too short to include becoming an adult. There may also be “omen formation,” that is, belief in an ability to foresee future untoward events. Children may also exhibit various physical symptoms, such as stomachaches and headaches.


F43.2Adjustment disordersa

F43.8Other

F43.9Not specified

F93Emotional disorders with onset specific to childhoodDisorders usually first diagnosed in infancy, childhood or adolescence

F93.0Separation anxiety disorder of childhood309.21Separation Anxiety Disorder

F93.1Phobic anxiety disorder of childhood

F93.2Social anxiety disorder of childhood

F93.8 disordersOther childhood emotional

F93.9Childhood emotional disorder, unspecified