Anxiety Disorders in Children and Adolescents

A Review of the Past 10 Years

Gail A. Bernstein, MD; Carrie M. Borchardt, MD; Amy R. Perwien, BA
Accepted September 7, !!".
Dr. Bernstein is Associate Pro#essor and Director and Dr. Borchardt is Associate Pro#essor and
Director o# $npatient Ser%ices, Di%ision o# Child and Adolescent Psychiatry, &ni%ersity o#
Minnesota Medical School, Minneapolis. Ms. Perwien is a 'rad(ate st(dent in the Department o#
Clinical and )ealth Psycholo'y, &ni%ersity o# *lorida, Gaines%ille.
Dr. Bernstein+s e##ort on this man(script was s(pported in part by ,$M) 'rant R-! M)./"0.. 1he
a(thors ac2nowled'e 3ois 3aitinen, M.B.A., M.M., #or man(script preparation.
Reprint re4(ests to Dr. Bernstein, Di%ision o# Child and Adolescent Psychiatry, Bo5 !" &M)C,
.-6 Delaware Street S7, Minneapolis, M, ""."".
89&R,A3 9* 1)7 AM7R$CA, ACAD7M: 9* C)$3D ; AD937SC7,1
PS:C)$A1R: !!/;0"<6=!
ABSTRACT
Objective. 1o critically re%iew the research on anxiety disorders in children and
adolescents, #oc(sin' on new de%elopments in the past 6 years.
Method. 1his re%iew incl(des recent articles which contrib(te to the
concept(ali>ation, assessment, and treatment o# childhood anxiety disorders.
Results. $n#ormation was or'ani>ed into a de%elopmental #ramewor2. Anxiety
disorders research has shown steady pro'ress.
Coclusios. More research is needed, partic(larly in the areas o#
ne(robiolo'ical basis o# anxiety disorders, lon'it(dinal st(dies, and treatment.
8. Am. Acad. Child Adolesc. Psychiatry, !!/, 0"?!@<6=!.
!e" #ords$ anxiety disorders, an5iolytics.
Aith the arri%al o# DSM=$B ?American Psychiatric Association, !!.@ C/D, anxiety
disorders in children and adolescents are de#ined 4(ite di##erently. 1he only
disorder remainin' o# the three anxiety disorders o# childhood and adolescence
in DSM=$$$=R ?American Psychiatric Association, !E7@ C"D is separation anxiety
disorder. Most cases o# o%eran5io(s disorder will now be s(bs(med (nder
'enerali>ed anxiety disorder, and a%oidant disorder has been concept(ali>ed
as social phobia.
1hese chan'es may pro%e ad%anta'eo(s. Research will now concentrate on
disorders seen in both children and ad(lts, there#ore decreasin' the
de%elopmental 'ap #rom earlier in%esti'ations ?Bernstein and Borchardt, !!@
C.D. 1his article re%iews what is 2nown abo(t anxiety disorders in childhood
and adolescence, #oc(sin' on the literat(re o# the past 6 years. $n#ormation is
presented #rom a de%elopmental perspecti%e.
%P&'%M&O(O)Y
Se%eral epidemiolo'ical st(dies indicate a hi'h pre%alence o# anxiety disorders
in nonre#erred children. $n a sample o# 7!- ele%en=year=olds, Anderson et al.
?!E7@ C7D #o(nd the #ollowin' rates o# anxiety disorders< 0."F #or separation
anxiety disorder, -.!F #or o%eran5io(s disorder, -..F #or simple phobia, and
.6F #or social phobia. Bowen et al. ?!!6@ C-0D reported a 0./F pre%alence o#
separation anxiety disorder and a -..F pre%alence o# o%eran5io(s disorder in a
sample o# -= to /=year=olds ?, G ,E/!@. $n .= to 7=year=olds ?, G ","!/@, the
li#etime pre%alence #or panic disorder was 6./F and #or 'enerali>ed anxiety
disorder was 0.7F ?Ahita2er et al., !!6@ C7"D.
A pediatric primary care sample o# 7= to =year=old children ?, G 066@ re%ealed a
=year pre%alence o# anxiety disorders o# "..F based on combinin' dia'noses
#rom parent and child str(ct(red psychiatric inter%iews. Simple phobia, separation
anxiety disorder, and o%eran5io(s disorder were the most pre%alent, with rates
o# !.-F, ..F, and ../F, respecti%ely ?BenHamin et al., !!6@ CD.
A*+&%TY &* &*,A*TS A*' PR%SC-OO( C-&('R%*
Te./era.et
1he relationship between early temperamental traits and the predisposition to the
de%elopment o# e5ternali>in' and internali>in' symptoms has been e5amined
lon'it(dinally in more than E66 children o%er a -=year period ?Caspi et al., !!"@
C-/D. Boys who were characteri>ed as con#ident and as ea'er to e5plore no%el
sit(ations at " years o# a'e were si'ni#icantly less li2ely to mani#est an5iety in
childhood and adolescence. Girls at a'es 0 and " years who were passi%e, shy,
#ear#(l, and a%oided new sit(ations were si'ni#icantly more li2ely to e5hibit
an5iety at later a'es. 1h(s, it appears that temperamental traits are related to
later reports o# an5iety in both boys and 'irls.
Mer'in' the concepts o# temperament and ne(robiolo'y has led to the e5citin'
#indin's related to beha%ioral inhibition in yo(n' children. Beha%ioral inhibition to
the (n#amiliar ?a laboratory=based temperamental constr(ct@ has been st(died
prospecti%ely in yo(n' children ?Ia'an et al., !EE@ C.6D. 1his temperamental
characteristic is de#ined as the tendency to be (n(s(ally shy or to show #ear and
withdrawal in no%el andJor (n#amiliar sit(ations.
1wo independent cohorts o# preschool children classi#ied as beha%iorally
inhibited or (ninhibited at - or 0 months ha%e been #ollowed lon'it(dinally by
Ia'an and collea'(es ?!EE@ C.6D. 1he researchers ha%e #o(nd that the
tendency to approach or withdraw #rom no%elty is an end(rin', temperamental
trait. Children with beha%ioral inhibition are di##erentiated #rom those witho(t
beha%ioral inhibition, not only on beha%ior b(t on physiolo'ical mar2ers incl(din'
hi'her, stable heart rate and acceleration o# heart rate with tas2s re4(irin'
co'niti%e e##ort. 9ther ne(rophysiolo'ical correlates o# beha%ioral inhibition ha%e
incl(ded increased tension in the laryn5 and %ocal cords, ele%ated sali%ary
cortisol le%els, ele%ated (rinary catecholamines, and lar'er p(pillary dilation
d(rin' co'niti%e tas2s.
A 0=year #ollow=(p st(dy #o(nd e%idence that children initially identi#ied as ha%in'
beha%ioral inhibition compared with those not initially classi#ied as beha%iorally
inhibited were si'ni#icantly more li2ely to ha%e m(ltiple psychiatric disorders and
to ha%e two or more anxiety disorders ?Biederman et al., !!0@ CED.
Speci#ically, a%oidant disorder, separation anxiety disorder, and a'oraphobia
were si'ni#icantly more pre%alent in the 'ro(p with beha%ioral inhibition. 1he
rates o# all anxiety disorders in the inhibited children increased mar2edly #rom
baseline to #ollow=(p. 1here#ore, beha%ioral inhibition appears to be a ris2 #actor
#or the de%elopment o# anxiety disorders in yo(n' children.
Attach.et
An inno%ati%e st(dy o# mothers with anxiety disorders ?n G E@ and their
preschool children ?n G -6@ e5amined mother=child attachment patterns
?Manassis et al., !!.@ C"0D. Mothers incl(ded . with panic disorder, 0 with
'enerali>ed anxiety disorder, and with obsessi%e=comp(lsi%e disorder. All
mothers were classi#ied as nona(tonomo(s ?i.e., insec(re@ in their c(rrent and
past attachment relationships. 7i'hty percent o# their preschool children were
insec(rely attached as determined with the Stran'e Sit(ation Proced(re
?Ainsworth and Aitti', !/!@ C-D. 1hree preschool children met criteria #or an
anxiety disorder; all three were insec(rely attached. 1h(s, insec(re attachment
may be a ris2 #actor #or the de%elopment o# childhood anxiety disorders.
Despite ha%in' mothers with nona(tonomo(s attachment histories, -6F o# the
preschool children were sec(rely attached. 1his s(''ests the presence o#
protecti%e #actors that help establish and maintain sec(re attachments. *or
e5ample, mothers o# sec(rely attached preschool children were less li2ely to
report depressi%e symptoms, had e5perienced #ewer recent stress#(l li#e e%ents,
and reported #eelin' more competent in parentin'.
Si5ty=#i%e percent o# the preschool children matched their mothers+ speci#ic
attachment classi#ications, ill(stratin' that a mother+s attachment pattern may be
repeated in the o##sprin'+s pattern o# attachment with her. A criticism o# this st(dy,
which sho(ld be corrected in #(t(re in%esti'ations, is that raters o# attachment
were not blind to maternal dia'nosis, which may ha%e introd(ced a bias when
codin' attachment patterns. Replication o# this wor2 with a lar'er sample si>e, as
well as #ollowin' the children lon'it(dinally, is warranted.
Manassis and collea'(es ?!!"@ C".D also reported that /"F o# the -6 preschool
children were classi#ied as beha%iorally inhibited. 1he presence o# beha%ioral
inhibition did not appear to increase the ris2 o# bein' insec(rely attached and
%ice %ersa. 1he possible interplay between beha%ioral inhibition and insec(re
attachment pattern and how this mi'ht contrib(te to the de%elopment o# an5iety
in yo(n' children co(ld not be answered in the st(dy.
$n#ants who are ambi%alently attached ?i.e., a type o# insec(re attachment@ ha%e
more an5iety dia'noses in childhood and adolescence ?Aarren, )(ston,
7'eland, and Sro(#e, personal comm(nication, !!/@. $n this lon'it(dinal st(dy,
attachment was meas(red at - months with the Stran'e Sit(ation Proced(re
and anxiety disorders at 7 years with a semistr(ct(red psychiatric inter%iew.
,either temperament theory nor attachment theory alone acco(nts #or the
de%elopment o# anxiety disorders ?Manassis and Bradley, !!.a@ C"D. An
inte'rated model which incorporates temperament, attachment pattern, and other
in#l(ences ?e.'., co'niti%e #actors, de%elopmental e%ents, tra(matic e%ents,
access to s(pport systems@ has been proposed by Manassis and Bradley
?!!.a@ C"D.
A*+&%TY &* C-&('R%*
9ne o# the dilemmas in anxiety disorder research and in clinical practice is to
de#ine what constit(tes an anxiety disorder, in comparison with normal an5iety.
Bell=Dolan et al. ?!!6@ C!D, who e5amined the pre%alence o# an5iety symptoms in
/- nonre#erred children with a semistr(ct(red psychiatric inter%iew, #o(nd that
isolated s(bclinical anxiety disorder symptoms were common. *rom !.EF to
06./F o# the nonre#erred children reported s(bclinical le%els o# indi%id(al
o%eran5io(s disorder symptoms and 6.7F to --./F endorsed s(bclinical
phobias. 1he most commonly endorsed an5iety symptoms were o%erconcern
abo(t competence, e5cessi%e need #or reass(rance, #ear o# the dar2, #ear o#
harm to an attachment #i'(re, and somatic complaints. $n 'eneral, 'irls endorsed
more an5iety symptoms than boys and yo(n'er children were more li2ely to
e5perience symptoms, partic(larly separation an5iety symptoms, than older
children.
Some children witho(t an anxiety disorder e5perience di##ic(lty #(nctionin' as a
res(lt o# their an5iety symptoms ?American Academy o# Child and Adolescent
Psychiatry, !!0@ C.D. 1h(s, an5iety symptoms may be more than a transient
de%elopmental phenomenon. $n an epidemiolo'ical st(dy o# ,!7 #irst='rade
children, $alon'o and collea'(es ?!!.@ C0ED #o(nd that sel#=reported an5iety
symptoms were moderately stable o%er a .=month period. An5iety was
si'ni#icantly associated with lower achie%ement; children with hi'h le%els o#
an5iety were 7.7 and -.. times more li2ely to be in the lowest 4(artile o# readin'
and math achie%ement, respecti%ely.
A#ter #ollowin' the children o%er . J- years, $alon'o and collea'(es ?!!"@ C0!D
#o(nd that an5iety in #irst 'rade si'ni#icantly predicted an5iety in #i#th 'rade. $n
addition, an5iety symptoms contrib(ted si'ni#icantly to #i#th='rade achie%ement
test scores. Speci#ically, #irst 'raders in the (pper third o# sel#=reported an5iety
symptoms were appro5imately 6 times more li2ely to be in the lower third o#
achie%ement in #i#th 'rade. 1he #indin's o# these st(dies s(''est the importance
o# not disco(ntin' symptoms as short=li%ed or insi'ni#icant in yo(n' children.
1he most common anxiety disorders o# middle childhood incl(de separation
anxiety disorder, o%eran5io(s disorder, and speci#ic phobias. Accordin' to
DSM=$B, the core #eat(re o# separation anxiety disorder is mar2ed an5iety abo(t
separation #rom si'ni#icant others or #rom home which is beyond that e5pected
#or the child+s de%elopmental le%el ?American Psychiatric Association, !!.@ C/D.
DSM=$$$=R de#ined the essential #eat(re o# o%eran5io(s disorder as mar2ed,
(nrealistic worry abo(t a %ariety o# sit(ations ?American Psychiatric Association,
!E7@ C"D.
DSM=$B de#ines a speci#ic phobia ?#ormerly 2nown as simple phobia@ as an
e5cessi%e and (nreasonable #ear o# circ(mscribed obHects or sit(ations where
the a%oidance, an5iety, or distress related to the #ear is associated with #(nctional
impairment or si'ni#icant distress ?American Psychiatric Association, !!.@ C/D.
&nli2e ad(lts, children may not reali>e that their #ears are mar2ed or
(nreasonable. Children with speci#ic phobias report e5treme #ear or dread,
physiolo'ical reactions, and a%oidance or #ear#(l anticipation when con#ronted
with the phobic stim(l(s ?Sil%erman and Rabian, !!0@ C/"D.
Sociodemo'raphic characteristics in a lar'e clinic sample ?, G EE@ o# children
with anxiety disorders were e5amined by 3ast et al. ?!!-@ C.ED. 1he children
with separation anxiety disorder had the earliest a'e o# onset ?mean G 7."
years@ and the yo(n'est a'e at inta2e ?mean G 6.0 years@ compared with
children with other anxiety disorders. 1he 'ender ratio #or each anxiety
disorder was relati%ely e4(al. Most o# the children were #rom middle class to
(pper middle class bac2'ro(nds and #rom intact #amilies, with the e5ception o#
those with separation anxiety disorder who were more commonly #rom sin'le=
parent and low socioeconomic stat(s homes.
Selecti%e m(tism, which is classi#ied in DSM=$B (nder Kother disorders o# in#ancy,
childhood, or adolescenceK ?American Psychiatric Association, !!.@ C/D, has
recently been concept(ali>ed as a type o# social phobia ?Blac2 and &hde, !!"@
C--D. 1he hallmar2 o# this disorder is the #ail(re to tal2 in speci#ic social sit(ations,
#or e5ample the classroom, while tal2in' in other settin's, s(ch as at home
?American Psychiatric Association, !!.@ C/D. Blac2 and &hde ?!!"@ C--D
systematically e%al(ated children ?7.0 LJ= -.E years@ with selecti%e m(tism ?, G
06@ and #o(nd that !6F met dia'nostic criteria #or social phobia e5hibited in ways
other than rel(ctance to spea2. Parent and teacher ratin's showed hi'h le%els o#
social an5iety, witho(t prominent ele%ations o# other psychiatric symptoms.
Altho('h this st(dy had se%eral methodolo'ical limitations incl(din' dia'noses
based on parent inter%iew only, lac2 o# a control 'ro(p, and all clinical inter%iews
completed by the same clinician, the #indin's s(''est that selecti%e m(tism
sho(ld be %iewed as a s(btype o# social phobia rather than as a distinct disorder.
A*+&%TY &* A'O(%SC%*TS
So(rces o# an5iety #or normal adolescents incl(de consolidation o# identity,
se5(ality, social acceptance, and independence con#licts. Ahen anxiety
disorder symptoms in normal adolescents were e5amined with a semistr(ct(red
psychiatric inter%iew, the symptoms that were more commonly reported by
adolescents than preadolescents incl(ded #ears o# hei'hts, p(blic spea2in',
bl(shin', e5cessi%e worry abo(t past beha%ior, and sel#=conscio(sness ?Bell=
Dolan et al., !!6@ C!D.
Adolescents can present with the same anxiety disorders that children present
with ?see pre%io(s section@. $n addition, in the perip(bertal period, indi%id(als
be'in to de%elop %(lnerability to other anxiety disorders incl(din' panic
disorder, a'oraphobia, and social phobia.
DSM=$B incl(des the dia'noses o# panic disorder with or witho(t a'oraphobia,
and a'oraphobia witho(t history o# panic disorder ?American Psychiatric
Association, !!.@ C/D. 1he criteria #or a panic attac2 incl(de a discrete episode
o# mar2ed #ear in which at least . o(t o# 0 physical and psycholo'ical symptoms
occ(r. 1he criteria #or a'oraphobia incl(de #ear o# bein' (nable to escape #rom
places in which the indi%id(al may e5perience a panic attac2 or where help may
be (na%ailable i# a panic attac2 occ(rs ?American Psychiatric Association, !!.@
C/D.
Panic disorder is (ncommon be#ore the perip(bertal period ?Blac2 and Robbins,
!!6; Ilein et al., !!-@ C-6,.0D. :et retrospecti%e reports o# ad(lts ha%e shown
panic disorder most commonly be'ins by adolescence or yo(n' ad(lthood
?Morea( and *ollett, !!0@ C"/D. 1he ,ational $nstit(te o# Mental )ealth
7pidemiolo'ic Catchment Area Pro'ram #o(nd the pea2 a'e o# onset #or panic
disorder was " to ! years ?Bon Ior## et al., !E"@ C7-D; howe%er, this also was
based on retrospecti%e reports.
)ayward and collea'(es ?!!-@ C0/D st(died 7". si5th= and se%enth='rade 'irls
to determine whether there was an association between the occ(rrence o# panic
attac2s and p(bertal sta'e, independent o# a'e. Res(lts showed ".0F o# the
sample o%erall reported a history o# at least one .=symptom panic attac2. ,one o#
the !. s(bHects who were at 1anner sta'e or - reported panic attac2s. Rates o#
panic attac2s increased with increasin' se5(al mat(rity, (p to a rate o# EF #or
s(bHects who were at 1anner sta'e ". 1he increasin' rates o# reported attac2s
were not acco(nted #or by increasin' a'e. 1his st(dy is an e5cellent e5ample o#
why panic disorder in yo(n' people deser%es more research attention. Research
in ad(lts has shown panic disorder to be lin2ed to ne(robiolo'ical #actors ?Sallee
and Greenawald, !!"@ C/D. Ahile spontaneo(s panic attac2s are rare be#ore
p(bertal chan'es be'in, adolescence is the pea2 period #or onset o# the disorder.
Prospecti%e st(dies o# children and adolescents are needed to pro%ide cl(es to
the biolo'ical chan'es in%ol%ed in the ac4(ired %(lnerability to panic disorder.
A'oraphobia has not been ri'oro(sly st(died in children and adolescents.
St(dies o# ad(lts with a'oraphobia ha%e loo2ed #or childhood antecedents,
partic(larly separation anxiety disorder. Ilein ?!/.@ C.-D, on the basis o#
retrospecti%e histories o# childhood separation an5iety in ad(lts with a'oraphobia,
hypothesi>ed that childhood separation an5iety co(ld e%ol%e into a'oraphobia in
ad(lthood. )owe%er, a re%iew o# st(dies that e5amined the association o#
separation an5iety in childhood with s(bse4(ent o(tcomes in ad(lthood #o(nd
that childhood separation an5iety is a nonspeci#ic prec(rsor to a n(mber o# ad(lt
psychiatric conditions incl(din' depression, as well as any anxiety disorder
?Morea( and *ollett, !!0@ C"/D.
A recent st(dy o# !. ad(lts with panic disorder showed that ".F retrospecti%ely
reported a history o# childhood anxiety disorder ?Pollac2 et al., !!/@ C"!D.
1hose with a history o# anxiety disorder in childhood, compared to those witho(t
this history, were si'ni#icantly more li2ely to ha%e comorbid other an5iety and
depressi%e disorders as ad(lts. 9# those ad(lts with a history o# anxiety
disorders, /..EF had had two or more anxiety disorders as children.
1he essential #eat(res o# social phobia incl(de e5cessi%e an5iety abo(t social or
per#ormance sit(ations in which the indi%id(al #ears scr(tiny or e5pos(re to
(n#amiliar persons ?American Psychiatric Association, !!.@ C/D. $n children, the
ability #or a'e=appropriate relationships with #amiliar people m(st be e%ident and
the an5iety occ(rs in peer sit(ations. Altho('h social phobia occ(rs in
preadolescents, onset most commonly occ(rs in early to midadolescence
?Schneier et al., !!-; Stra(ss and 3ast, !!0@ C/-,76D.
Similar n(mbers o# males and #emales de%elop social phobia. Comorbidity with
other anxiety disorders and a##ecti%e disorders is common. $n a clinic sample,
Stra(ss and 3ast ?!!0@ C76D #o(nd //F o# social phobic s(bHects had conc(rrent
anxiety disorders, and 7F had a conc(rrent a##ecti%e disorder. $ndi%id(als with
the DSM=$$$=R dia'nosis o# a%oidant disorder were similar to those with social
phobia in sociodemo'raphic and comorbidity patterns ?*rancis et al., !!-; 3ast
et al., !!-@ C06,.ED. )owe%er, the a'e o# onset is di##erent, with a%oidant
disorder presentin' at an earlier a'e than social phobia ?*rancis et al., !!-@
C06D. 1his #its with a%oidant disorder and social phobia as the same disorder on a
de%elopmental contin((m. $n normal de%elopment, #ear o# (n#amiliar people
occ(rs earlier than social=e%al(ati%e #ears. 1h(s, there was little e%idence to
s(pport a%oidant disorder as a separate entity. 1his led to the concept(ali>ation
o# a%oidant disorder as social phobia in DSM=$B.
DSM=$B 'enerali>ed anxiety disorder is characteri>ed by e5cessi%e worry abo(t
a %ariety o# sit(ations ?American Psychiatric Association, !!.@ C/D. 1he indi%id(al
#inds it hard to control the an5iety. DSM=$$$=R criteria #or o%eran5io(s disorder
were #o(nd to be %a'(e, nonspeci#ic, and to o%erlap with criteria o# other
disorders ?Beidel, !!; Aerry, !!@ CE,7.D. 1hese were some o# the reasons #or
elimination o# this disorder in DSM=$B. $n DSM=$B, o%eran5io(s disorder is
incl(ded (nder 'enerali>ed anxiety disorder. 1he criteria #or 'enerali>ed
anxiety disorder in DSM=$B are modi#ied #or children so that only one o# the si5
accompanyin' symptoms is re4(ired.
)owe%er, 'enerali>ed anxiety disorder in children and adolescents has not
been well researched. $n an anxiety disorders clinic sample, none o# the EE
children and adolescents #(l#illed DSM=$$$=R criteria #or 'enerali>ed anxiety
disorder ?3ast et al., !!-@ C.ED. *(rthermore, #amily history data, as well as data
#rom a prospecti%e st(dy o# children with anxiety disorders, ha%e not pro%ided
stron' s(pport #or a lin2 between o%eran5io(s disorder and 'enerali>ed anxiety
disorder ?3ast, !!0@ C.7D. *(t(re st(dies will determine the applicability o#
c(rrent criteria #or 'enerali>ed anxiety disorder to children and adolescents.
ASS%SSM%*T O, A*+&%TY
1he KPractice Parameters #or the Assessment and 1reatment o# Anxiety
DisordersK ?American Academy o# Child and Adolescent Psychiatry, !!0@ C.D
note important areas to emphasi>e in the assessment o# anxiety disorders in
children and adolescents. 1he onset, de%elopment, and conte5t o# an5iety
symptoms, as well as in#ormation re'ardin' the child+s or adolescent+s
de%elopmental, medical, school, and social history, and a #amily psychiatric
history sho(ld be obtained. Mental stat(s e5amination and assessment o# school
#(nctionin' are critical.
*or the assessment o# an5iety, str(ct(red psychiatric inter%iews, clinician ratin'
scales, sel#=report instr(ments, and parent report meas(res are a%ailable ?1able
@. $t is (se#(l to incorporate se%eral types o# instr(ments. Beca(se o# the
s(bHecti%e nat(re o# an5iety symptoms, it is important to incl(de meas(res that
assess an5iety thro('h the child or adolescent+s %iewpoint. Since there is o#ten
low concordance between child and parent reports o# an5iety ?Ilein, !!@ C..D,
parental reports o##er an additional perspecti%e. )owe%er, *ric2 and collea'(es
?!!.@ C0D #o(nd that mothers o%erreport an5iety symptoms in their children
related to increased le%el o# maternal an5iety. 1his hi'hli'hts the importance o#
clinician awareness o# parental an5iety le%el. Clinician ratin' scales are (se#(l
beca(se they inte'rate the clinician+s e5pertise and the child or adolescent+s
report o# an5iety symptoms. *inally, it is (se#(l to combine a str(ct(red
psychiatric inter%iew which will pro%ide dia'noses, with ratin's o# the se%erity o#
the an5iety symptoms.
1able . $nstr(ments #or Assessment o# An5iety in
Children and Adolescents
1here are se%eral limitations o# an5iety scales. 9ne di##ic(lty is the o%erlap o#
symptoms on sel#=report meas(res o# an5iety and depression ?Brady and
Iendall, !!-@ C-.D. *(rthermore, altho('h the state %ers(s trait dichotomy o#
an5iety has been considered, it has not yet been well di##erentiated with ratin'
scales ?Stallin's and March, !!"@ C/!D. As noted in 1able , only the State=1rait
An5iety $n%entory #or Children ?Spielber'er, !70@ C/ED was speci#ically de%eloped
to e5amine both state and trait an5iety.
(O*)&T0'&*A( ST0'&%S
Prospecti%e, lon'it(dinal st(dies are needed to determine whether anxiety
disorders in children and adolescents are persistent and to determine how the
symptoms loo2 at di##erent sta'es o# de%elopment. Se%eral prospecti%e st(dies
are be'innin' to emer'e. Cantwell and Ba2er ?!E!@ C-"D st(died yo(n' children
with speech and lan'(a'e disorders. *or those with anxiety disorders, the
remission rate o# anxiety disorder at .= to "=year #ollow=(p was 77F.
A 0= to .=year #ollow=(p o# re#erred children and adolescents with anxiety
disorders ?, G 6-@ showed a hi'h remission rate, with E-F no lon'er meetin'
criteria #or their initial anxiety disorder ?3ast et al., in press@ C.!D. 9# those who
went into remission, the maHority ?/EF@ did so d(rin' the #irst year o# #ollow=(p.
9# the anxiety disorders e5amined, separation anxiety disorder had the
hi'hest reco%ery rate at !/F, with panic disorder ha%in' the lowest rate o#
remission at 76F. 7arly a'e o# onset and older a'e at inta2e were #actors
predictin' slower reco%ery. 9%eran5io(s disorder was the slowest to remit.
D(rin' the #ollow=(p period, 06F o# the children with anxiety disorders
de%eloped new psychiatric disorders, and hal# o# these children de%eloped new
anxiety disorders.
Cohen and collea'(es ?!!0@ C-!D prospecti%ely #ollowed an epidemiolo'ical
sample o# 70. children a'ed ! to E years. 1he li2elihood o# ha%in' the same
disorder redia'nosed at #ollow=(p was hi'her i# symptoms at baseline
assessment were se%ere. *or o%eran5io(s disorder, the only anxiety disorder
st(died, .7F o# se%ere cases were redia'nosed at - J-=year #ollow=(p.
1here#ore, nonre#erred children may ha%e persistence o# symptoms. More
st(dies that #ollow yo(ths with anxiety disorders prospecti%ely thro('ho(t
childhood and adolescence and into ad(lthood are needed.
TR%ATM%*T O, &*,A*TS A*' PR%SC-OO( C-&('R%*
Since an insec(re bond between parent and child may be an important #actor in
the de%elopment o# an5iety symptoms in in#ants and preschool children,
treatment aimed at impro%in' the interactions between parent and child may be
cr(cial. K)elpin' an5io(s ad(lts resol%e the losses and tra(matic e5periences o#
the past may indirectly bene#it their children by impro%in' the parent=child
attachment relationship ... red(cin' stress#(l li#e e%ents, and increasin' their
sense o# competence as parents may also help these indi%id(als de%elop sec(re
attachment relationships with their childrenK ?Manassis et al., !!., p. @ C"0D.
Aor2in' with parents or the parent=child dyad may be more pre%enti%e o# an5iety
and anxiety disorders than treatin' preschool children indi%id(ally. Moreo%er,
attendin' to temperamental #actors may also be pre%enti%e.
TR%ATM%*T O, C-&('R%* A*' A'O(%SC%*TS
$n 'eneral, a m(ltimodal approach is incorporated in the treatment o# a child or
adolescent with an anxiety disorder. 1he KPractice Parameters #or the
Assessment and 1reatment o# Anxiety DisordersK recommends that, when
de%elopin' a treatment plan, consideration be 'i%en to the #ollowin' components<
#eedbac2 and ed(cation to the parents and child abo(t the speci#ic disorder,
cons(ltation to primary care physicians and school personnel, co'niti%e=
beha%ioral inter%entions, psychodynamic psychotherapy, #amily therapy, and
pharmacotherapy. 1he Practice Parameters recommends some speci#ic
inter%entions #or speci#ic anxiety disorders; #or e5ample, a plan #or separation
?e.'., ret(rn to school@ #or children with separation anxiety disorder and
systematic desensiti>ation and e5pos(re #or speci#ic phobia.
Co1itive2Behavioral Thera/"
Co'niti%e=beha%ioral therapy inte'rates beha%ioral approaches ?e.'., e5pos(re@
and co'niti%e techni4(es ?e.'., copin' sel#=statements@. Co'niti%e techni4(es
emphasi>e restr(ct(rin' an5io(s tho('hts into a more positi%e #ramewor2,
res(ltin' in more asserti%e and adapti%e beha%iors ?3eonard and Rapoport,
!!@ C"6D. Children a'ed appro5imately 6 years and older can bene#it #rom
co'niti%e techni4(es.
Iendall ?!!.@ C.D compared / wee2s o# co'niti%e=beha%ioral therapy %ers(s E
wee2s o# waitin'=list control #or .7 children ?a'ed ! to 0 years@ with anxiety
disorders. 1he co'niti%e=beha%ioral pac2a'e incl(ded copin' sel#=statements,
modelin', e5pos(re, role=playin', rela5ation trainin', and contin'ent
rein#orcement. A 'reater n(mber o# treated s(bHects than waitin'=list controls
reported clinically si'ni#icant decreases in an5iety and depression a#ter the
inter%ention. Many s(bHects recei%in' co'niti%e=beha%ioral therapy did not meet
criteria #or an an5iety dia'nosis posttreatment and at =year #ollow=(p.
Ps"chod"a.ic Thera/"
Psychodynamic psychotherapy is an o(t'rowth o# psychoanalysis ?Bemporad,
!!@ C6D. 1his approach #oc(ses on (nderlyin' #ears and an5ieties. $mportant
themes in treatin' children with anxiety disorders incl(de resol%in' iss(es o#
separation, independence, and sel#=esteem ?3eonard and Rapoport, !!@ C"6D.
1wo st(dies s(pport the (se o# psychodynamic psychotherapy in children with
anxiety disorders. A treatment st(dy o# 7= to 6=year=old boys ?, G -@ with
o%eran5io(s disorder and learnin' di##ic(lties compared wee2ly, #o(r times per
wee2, and wee2ly #ollowed by #o(r times per wee2 psychodynamic
psychotherapy ?)einic2e and Ramsey=Ilee, !E/@ C07D. Boys seen more o#ten
than once a wee2 showed better adaptation and enhanced capacity #or
relationships at the end o# treatment and year a#ter treatment, and they also
showed 'reater impro%ement in readin' in the year a#ter completion o# treatment.
$n a retrospecti%e chart re%iew o# 0"- children assi'ned DSM=$$$=R dia'noses,
primarily an5iety andJor depressi%e disorders, psychotherapy one to three times
per wee2 was compared with psychoanalytic psychotherapy #o(r to #i%e times per
wee2 ?1ar'et and *ona'y, !!.@ C7D. Combinin' the children who recei%ed at
least / months o# either treatment, 7-F showed impro%ement in adaptation.
$mpro%ement was predicted by yo(n'er a'e, presence o# phobic symptoms,
lon'er d(ration o# treatment, and more intensi%e treatment.
Phar.acolo1ical Treat.et
Ahile anxiety disorders is one o# the most pre%alent cate'ory o#
psychopatholo'y in children and adolescents, the st(dies e%al(atin'
pharmacolo'ical treatments #or these disorders are scarce. $n 'eneral, the
sample si>es o# these st(dies ha%e been small and the placebo response rates
are hi'h. Both o# these #actors limit the li2elihood o# #indin' si'ni#icant di##erences
between antian5iety medication and placebo in treatin' an5iety symptoms.
Commonly considered medications #or an5iety symptoms incl(de tricyclic
antidepressants and ben>odia>epines. A third consideration is the serotonin
re(pta2e inhibitors. 9ther choices are beta=bloc2ers, b(spirone, and monoamine
o5idase inhibitors ?Allen et al., !!" C0D, #or recent re%iew@.
*o(r do(ble=blind, placebo=controlled st(dies o# tricyclic antidepressants #or
school re#(sal associated with an5iety show contrastin' res(lts ?Berney et al.,
!E; Bernstein et al., !!6; Gittelman=Ilein and Ilein, !70; Ilein et al., !!-@
C-,7,00,.0D. 1he con#lictin' #indin's most li2ely are e5plained by di##erences in
dosa'es, dia'nostic comorbidity patterns, d(ration o# treatment, and conc(rrent
therapy. Case reports s(pport the (se o# tricyclic antidepressants #or children and
adolescents with panic disorder ?Blac2 and Robbins, !!6; Garland and Smith,
!!6@ C-6,0-D.
$n an open=label st(dy ?Simeon and *er'(son, !E7@ C//D #ollowed by a do(ble=
blind placebo=controlled st(dy ?Simeon et al., !!-@ C/7D, res(lts ?altho('h not
statistically si'ni#icant@ s(''ested that alpra>olam may be (se#(l in allayin'
an5iety symptoms in children with o%eran5io(s or a%oidant disorders. $n a
do(ble=blind crosso%er st(dy, Graae and collea'(es ?!!.@ C0.D e%al(ated
clona>epam %ers(s placebo in children with anxiety disorders ?primarily
separation anxiety disorder@. ,ine o# - s(bHects showed moderate to mar2ed
impro%ement with clona>epam and / o# - no lon'er met criteria #or anxiety
disorder at the end o# the st(dy.
$n addition, st(dies are emer'in' that s(pport ben>odia>epines #or teena'ers
with panic disorder. *o(r adolescents with panic disorder were s(ccess#(lly
treated with clona>epam in an open=label trial ?I(tcher and Mac2en>ie, !EE@
C."D. 1he #re4(ency o# panic attac2s and baseline le%el o# an5iety decreased. $n a
do(ble=blind, placebo=controlled st(dy, adolescents recei%in' clona>epam
showed decreases in the n(mber o# panic attac2s, in an5iety scores, and on a
school and social impairment scale ?I(tcher and Reiter, personal
comm(nication, !!/@.
Selecti%e serotonin re(pta2e inhibitors are now bein' considered #or the
treatment o# childhood anxiety disorders. *i%e children with anxiety disorders
recei%ed at least / wee2s o# #l(o5etine in open=label trials ?Manassis and
Bradley, !!.b@ C"-D. All #i%e showed a decrease in an5iety symptoms per sel#=
report and parental report. An open=label st(dy o# #l(o5etine in - children with
separation anxiety disorder, social phobia, or o%eran5io(s disorder showed
EF had moderate to mar2ed impro%ement ?Birmaher et al., !!.@ C!D. Bene#it
was appreciated a#ter / to E wee2s o# treatment. A -=wee2 do(ble=blind,
placebo=controlled st(dy o# #l(o5etine in " children with selecti%e m(tism
demonstrated si'ni#icant impro%ement on parental ratin's o# an5iety and m(tism
in the #l(o5etine 'ro(p ?Blac2 and &hde, !!.@ C-D. :et children in both the
imipramine and #l(o5etine 'ro(ps remained symptomatic at the end o# the st(dy.
An5iolytics may be considered as part o# a m(ltimodal treatment plan.
Medications are more li2ely to be considered in older children and adolescents
and in those with se%ere symptomatolo'y. Dia'nostic comorbidity and side
e##ects pro#ile are important #actors in the selection o# the class o# antian5iety
medication ?Bernstein, !!.@ C0D.
CO*C(0S&O*S
Dramatic disco%eries ha%e incl(ded the identi#ication o# beha%ioral inhibition as
an early and persistent temperamental ris2 #actor associated with ne(robiolo'ical
mar2ers, which predicts the later de%elopment o# prep(bertal anxiety disorders.
9ther e5citin' ad%ances incl(de the concept(ali>ation o# selecti%e m(tism as a
type o# social phobia and the reco'nition that the %(lnerability to panic disorder is
a #(nction o# p(bertal chan'es, th(s lendin' s(pport to the biolo'ical basis o# this
disorder. 1he de%elopment o# practice parameters, o# #oc(sed, speci#ic co'niti%e=
beha%ioral pac2a'es #or the treatment o# anxiety disorders, and the early
in%esti'ation o# selecti%e serotonin re(pta2e inhibitors #or tar'etin' an5iety are
hi'hli'hts in the treatment arena. Areas #or #(t(re research incl(de the
ne(robiolo'ical basis o# anxiety disorders ?especially panic disorder@,
lon'it(dinal st(dies, and in%esti'ation o# combined treatments.
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4 A( Acad Child Adolesc !s&chiatr& 199- 6e*te(berG28(9)$111;-1119
Copyright 1996 American Academy of Child and Adolescent Psychiatry. All rights reserved
Published by Lippincott Williams Wil!ins
1able . $nstr(ments #or Assessment o# An5iety in Children and Adolescents
4 A( Acad Child Adolesc !s&chiatr& 199- 6e*te(berG28(9)$111;-1119
Copyright 1996 American Academy of Child and Adolescent Psychiatry. All rights reserved
Published by Lippincott Williams