The treatment of anxiety disorders in children and adolescents

Abstract

Anxiety disorders are the most common psychiatric conditions in the pediatric population, with prevalence estimates ranging from 5–18%. Children and adolescents with excessive anxiety often meet diagnostic criteria for a number of disorders within the DSM-IV. Unfortunately, the current diagnostic system is controversial because of high rates of symptom overlap, comorbidity with other psychiatric disorders, and lack of biological markers that would support a more empirical anxiety nosology.

Treatment strategies for pediatric anxiety disorders have important historical roots. Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for pediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder; however, several large, methodologically sound psychopharmacotherapy trials are underway for pediatric anxiety disorders.

This update will review the current status of psychosocial and psychopharmacologic treatment of pediatric anxiety disorders. In addition, a brief discussion of nosology, epidemiology, and developmental course of anxiety is included. Preliminary psychopharmacology treatment and CBT treatment algorithms are presented for pediatric anxiety disorders, based on the best available data. Recommendations for future research directions are also discussed.

Introduction

Anxiety is considered a normal emotion experienced throughout life. In healthy individuals, anxiety plays important protective and adaptive functions during development. In contrast, an anxiety disorder is characterized by irrational fear or worry causing significant distress, impairment in functioning, or both. For instance, separation anxiety is considered a normal developmental experience during early childhood; however, separation anxiety disorder (SAD) may be diagnosed when fear of separation is excessive, persistent, or present later than expected during development, resulting in difficulties with peer interaction, school performance, or relationships with family members. Similarly, social reticence (i.e., shyness) and the normal stranger anxiety of early childhood are differentiated from the diagnosis of social phobia (SoP) by the severity of anxiety and the presence of impairment. Unfortunately, symptoms of an anxiety disorder are often dismissed in children and adolescents as acceptable given the circumstances or attributed to normal stress.

Anxiety symptoms are a key characteristic of numerous psychiatric disorders. At least 13 separate anxiety-related disorders can be diagnosed in youth according to criteria in the DSM-IV (American Psychiatric Association, 1994; see Table 1). Extensive symptom overlap among the anxiety disorders, and between anxiety disorders and other psychiatric disorders, contribute to diagnostic uncertainty and controversy. For example, school refusal may be an anxiety-related symptom associated with SAD, SoP, specific phobia (SpP), generalized anxiety disorder (GAD), or other disorders (Last and Strauss 1990). Similarly, performance anxiety may be a fear of humiliation associated with SoP or a fear of incompetence associated with GAD, for example. By the same logic, fear of illness may be a symptom of hypochondriasis (HC), SpP, GAD, or obsessive-compulsive disorder (OCD). Comorbid mood disorders, substance use disorders, attention-deficit/hyperactivity disorder (ADHD), and stresses associated with psychosocial disadvantage also make it difficult to identify a pediatric anxiety disorder. Furthermore, no genetic, environmental, or pathophysiological data exists for a more valid nosology of anxiety disorders.

An alternative approach to organizing the various anxiety-related disorders conceptualizes these disorders as distinct types of fear or anxiety based on core symptoms (Banghoo and Riddle 1999; Table 1). These four types of fear include 1) specific fears, that is, SAD (fear of being alone), SoP and selective mutism (SM: fear of humiliation), SpP (fear of danger), agoraphobia (AP: fear of the marketplace), panic disorder (PD: fear of impending doom), and HC (fear of illness); 2) general worries, that is, GAD and unspecific somatization (US); 3) excessive anxious response to stress, that is, adjustment disorder with anxiety (AD), acute stress disorder (ASD), and posttraumatic stress disorder (PTSD); and 4) repetitive thoughts, behaviors, or both directed at decreasing anxiety, that is, OCD. Prominent physical symptoms of anxiety, including panic attacks, may be associated with any of the above anxiety-related disorders and a number of other psychiatric disorders.

Anxiety disorders are among the most common psychiatric disorders in youth. Epidemiological data suggest that these disorders occur in 5–18% of all children and adolescents (see Costello and Angold 1995 for a comprehensive review). Typical age-of-onset for clinically referred childhood anxiety disorders is between 7 and 12 years (Last et al 1992). Retrospective reports of adults with anxiety disorders indicate that as many as 80% report the development of anxiety symptoms prior to age 18 years (Pauls et al 1995; G. Nestadt et al, unpublished data, 1999).

Just as stranger anxiety and separation anxiety symptoms are seen during specific stages of normal development, anxiety disorders also appear more common during specific stages of development. Separation anxiety disorder appears more commonly than GAD in early childhood, whereas GAD appears more commonly than SAD in late childhood and adolescence Kashani and Orvashel 1990, Last et al 1992, which may be correlated with levels of social maturity (Westenberg et al 1999). Pediatric anxiety disorders may also be continuous with adult anxiety disorders. Childhood SAD may be an antecedent to PD and AG in adulthood (Gittleman-Klein and Klein 1984). Adolescents with SpP may be at risk for SpP in adulthood, and adolescents with SoP may be at risk for adult SoP. Similarly, adolescents with GAD, PD, or major depressive disorder (MDD) may be at risk for GAD, PD, MDD, or a combination of these disorders in adulthood (Pine et al 1998).