Chapter 41. Anxiety Disorders in Children and Adolescents

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

   1. recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

   2. persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

   3. persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

   4. persistent reluctance or refusal to go to school or elsewhere because of fear of separation

   5. persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

   6. persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

   7. repeated nightmares involving the theme of separation

   8. repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

2. The duration of the disturbance is at least 4 weeks.

3. The onset is before age 18 years.

4. The disturbance causes clinically significant distress or impairment in social, academic (occupation), or other important areas of functioning.

5. The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia.

Specify if:

Early onset: if onset occurs before age 6 years.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

Separation anxiety disorder (SAD) occurs in 2–4% of children and adolescents. It represents about 50% of all referrals for evaluation of anxiety disorder at this age. SAD may be slightly more prevalent in girls and in families of lower socioeconomic status. School refusal is equally common in all socioeconomic groups. Its incidence is 1–2% in school-aged children, and it may be more common in boys.

Etiology

SAD is linked to insecure attachment (see Chapter 45). It may be precipitated by loss, separation, or the threat of either. Parental anxiety and an enmeshed mother–child relationship is commonly associated with this condition. The combination of parental anxiety and depression is an additional risk factor. The prevalence of anxiety disorders in other family members might indicate a genetic factor.

A psychodynamic theory concerning the etiology of SAD postulates the following: (1) The mother has a hostile-dependent relationship with her own mother, (2) the mother is lonely and unsatisfied in her marriage, (3) following a threat to security, the child responds to an overly dependent relationship with the mother, (4) the mother is gratified by the child's overdependence, (5) the mother and child develop a mutually ambivalent hostile-dependent relationship, (6) the child responds to the normal stresses of school with fear and avoidance, (7) the mother is pleased by having the child at home, while at the same time annoyed by it, and (8) both mother and child focus on the somatic symptoms of anxiety and become convinced that the child has a physical disorder.

Genetics

SAD, like other many other neurodevelopmental disorders of childhood onset, is likely to be associated with multiple vulnerability genes. Twin studies suggest that different genes may be playing a role in mediating this condition in males versus females. It also appears that the heritability of SAD is greater for girls than for boys.

Clinical Findings

The average age at onset is 8–9 years. Children with SAD exhibit severe distress when separated or threatened with separation from their parent, usually the mother. Fearing that harm will befall the attachment figure or themselves, they typically want to sleep in the parental bed, refuse to be alone, plead not to go to school, have nightmares about separation, and exhibit numerous somatic symptoms when threatened with separation. For example, when it is time to go to school these children complain of abdominal pain, nausea, vomiting, diarrhea, urinary frequency, and palpitations. Sometimes they have to be forced to leave the house. They may run away and hide near the home.

Differential Diagnosis (Including Comorbidity)

See end of Chapter.

Treatment

See end of Chapter.

Complications/Adverse Outcomes of Treatment

See end of Chapter.

Prognosis

See end of Chapter.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

2. The person finds it difficult to control the worry.

3. The anxiety and worry are associated with one of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).

   1. restlessness or feeling keyed up or on edge

   2. being easily fatigued

   3. difficulty concentrating or mind going blank

   4. irritability

   5. muscle tension med

   6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive–Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

6. The disturbance is not true to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Generalized anxiety disorder (GAD) involves excessive anxiety and worry about a number of events or activities (e.g., school performance, social relationships, clothes), causing significant impairment or distress, manifested by somatic symptoms, self-consciousness, and social inhibition.

Epidemiology

GAD occurs in about 3% of children and in 6–7% of adolescents. The sex ratio is equal. GAD is more prevalent among children of higher socioeconomic status.

Etiology

As with SAD, GAD is associated with a familial concentration of anxiety disorders. Parents of children with GAD have been described as anxious and hypercritical, with high expectations for their children's performance. Children with GAD are more likely to have exhibited behavioral inhibition when younger, a temperamental trait involving shyness and withdrawal from unfamiliar situations. Behavioral inhibition is probably genetically determined.

Genetics

Twin studies suggest that genetic factors appear to play only a modest role in the etiology of GAD.

Clinical Findings

The average age at onset of GAD is 10 years. Children with GAD worry about their clothes, schoolwork, social relationships, and sporting performance—past, present, and future. They are exceedingly self-conscious, have low self-esteem, and complain of many somatic symptoms (particularly abdominal pain and headaches).

Differential Diagnosis (Including Comorbidity)

See end of Chapter.

Treatment

See end of Chapter.

Complications/Adverse Outcomes of Treatment

See end of Chapter.

Prognosis

See end of Chapter.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Avoidant Personality Disorder: In general, avoidant personality disorder involves pervasive social inhibition, a sense of inadequacy, and hypersensitivity to criticism, which leads to avoidance of academic and social involvement, a preoccupation with being rejected, and low self-esteem.

2. Social Phobia: In general, social phobia involves marked, persistent fear of social or performance situations that involve potential scrutiny by other people. The fear is sufficiently severe to interfere with normal social and academic functioning.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

The prevalence of social phobia among children and adolescents is 0.9–1.1%. Girls predominate over boys in a ratio of about 7:3. The prevalence of social phobia has been estimated at 0.08% and 0.7% in 7-year-old and 5-year-old children, respectively. Among children in these two age groups, girls predominate over boys in a ratio of about 2:1.

Etiology

Adults with social phobia often report that the phobia was precipitated by a traumatic event. Compared to Attention-deficit hyperactivity disorder and to normal controls, anxiety disorders are more common among first-degree relatives of children with anxiety disorders (including avoidant personality disorder and social phobia), but there is no tendency for children with avoidant personality disorder or social phobia to have parents with the same anxiety disorder. In contrast to the development of GAD, behaviorally inhibited children show no greater tendency than do normal children to develop avoidant personality disorder or social phobia. However, the parents of behaviorally inhibited children are more likely to have, or to have had, social phobia, avoidant personality disorder, or GAD. There may be a familial predisposition to the development of fear. Social phobia has been associated with the predisposition of some children to assume a low status position in the social dominance hierarchy of their peers.

Genetics

There is evidence that SAD has a strong familial basis, but there are few studies that involve cases in the pediatric age range. In addition to specific vulnerability genes contributing to this behaviorally complex phenotype, there is also the possibility that temperamental risk factors associated with the disorder may be genetically transmitted.

Clinical Findings

Children with avoidant personality disorder or social phobia experience anxiety in the company of other people or when expected to perform in some way. For example, when unfamiliar visitors arrive, they hide; they prefer single playmates to peer groups; they avoid sports events and parties; and they detest taking examinations, reading aloud in class, eating in front of others, using public toilets, answering telephones, or speaking up to people in authority. Most of these children are afraid of two or more situations. When threatened, they experience the somatic concomitants of anxiety (e.g., rapid breathing, palpitations, shakiness, chills, sweating, nausea).

Differential Diagnosis (Including Comorbidity)

See end of Chapter.

Treatment

See end of Chapter.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Both (1) and (2): (1) recurrent unexpected Panic Attacks; and (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

   1. persistent concern about having additional attacks

   2. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”); or

   4. a significant change in behavior related to the attacks

2. Absence or absence of agoraphobia (anxiety about being in specific places of situations leading to avoidance or marked distress).

3. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., c. a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

4. The Panic Attacks are not better accounted for by another mental disorder, such as. Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive–Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Post-traumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

In general, panic disorder involves recurrent, unexpected panic attacks, with fear of future attacks, with or without agoraphobia (a fear of being somewhere from which escape might be difficult such as in a crowd, on a bridge, or while traveling). The disorder is manifested as acute anxiety with autonomic concomitants (e.g., racing heart; dilated pupils; rapid breathing; cold, sweaty palms), and it may present as hyperventilation, with tetany. See Chapter 19 for diagnostic criteria.

Epidemiology

Panic disorder appears to be equally prevalent in both sexes. Its base-rate prevalence is not known.

Etiology

In adults with panic disorder, lactate infusion provokes panic symptoms, a phenomenon not found in other anxiety disorders. Agoraphobia is probably a secondary phenomenon, produced by conditioning, when the individual is apprehensive between attacks about the next panic attack. Despite plausible hypotheses, no evidence has been found for an early history of loss or traumatic separation in adults with panic disorder, and childhood SAD is related to adult anxiety disorders generally, not to panic disorder specifically. It is not clear whether childhood SAD predisposes to adult agoraphobia; however, childhood SAD is statistically associated with the early onset of adult panic disorder. An association has been found between panic disorder and earlier traumatic suffocation experiences such as near drowning.

Genetics

First-degree relatives of patients with panic disorder meet criteria for the disorder in 20–40% of cases. Twin studies also have shown a higher concordance for monozygotic than dizygotic twin pairs. No specific vulnerability genes have been identified.

Clinical Findings

Panic disorder can begin as early as the preschool years, but the peak age at onset is 15–19 years. About 25% of patients report an onset prior to 15 years of age. The condition has probably been underdiagnosed and confused with SAD. Typical symptoms are episodes of hyperventilation, trembling, palpitations, shortness of breath, sweating, numbness, depersonalization, chest pain, choking, fear of dying, dizziness, and fainting.

Treatment

See end of Chapter.

Complications/Adverse Outcomes of Treatment

See end of Chapter.

Prognosis

See end of Chapter.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Consistent failure to speak in specific social situations (in which there is an expectation of speaking, e.g., at school) despite speaking in other situations.

2. The disturbance interferes with educational or occupational achievement or with other social communication.

3. The duration of the disturbance is at least 1 month (not limited to the first month of school).

4. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

5. The disturbance is not better accounted for by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

Selective mutism is more common in girls than boys. Prevalence estimates have varied from 0.08% to 0.7%.

Etiology

The cause of selective mutism is probably multifactorial. Four types of the disorder have been postulated. In symbiotic mutism, the child manipulates the environment, using shyness and clinging to avoid separation. In passive-aggressive mutism, a child scapegoated by his or her peers trenchantly refuses to speak when called on to do so. Reactive mutism is precipitated by a stressor such as illness, separation, or abuse. In speech phobic mutism, the child is afraid to hear his or her own voice.

Shyness, taciturnity and selective mutism run in families. Selective mutism may be a form of social anxiety. One study found a high prevalence of comorbid social phobia, avoidant personality disorder, and simple phobia in this condition, along with a familial aggregation of social phobia and selective mutism. Some studies suggest that selective mutism may be associated with subtle expressive language impairment.

Genetics

Like other many other neurodevelopmental disorders of childhood onset, it is likely that there are multiple vulnerability genes associated with this condition.

Clinical Findings

The age at onset of selective mutism is 1–5 years (average, 2.7 years). Children with selective mutism are most reluctant to speak at school, away from home, to adults, and to unfamiliar people. They are more likely to speak to peers than to teachers. One study found that 13% of children with selective mutism had a learning disorder and 10% had a history of delayed language development, but all had normal speech and language by 5 years of age. No clear association has been found between trauma and the onset of selective mutism, nor has the often-reported association with oppositional behavior been corroborated. Selective mutism may be regarded more appropriately as a symptom of social anxiety, akin to the “freezing” that some adults with social phobia experience when called on to speak in public.

Treatment

See remainder of this Chapter.

Complications/Adverse Outcomes of Treatment

See remainder of this Chapter.

Prognosis

See remainder of this Chapter.

Differential Diagnosis (Including Comorbid Conditions)

SAD and school refusal are most likely to be confused with physical disorders when they have salient somatic anxiety equivalents. Thus gastrointestinal symptoms can be confused with peptic ulcer, esophageal reflux, abdominal emergency, or disorders associated with bowel hurry. SAD with school refusal can also masquerade as chronic fatigue syndrome, chronic muscular pain, and prolonged convalescence from infectious mononucleosis. In panic disorder, mitral valve prolapse should be investigated only if auscultation indicates the need to do so.

Selective mutism should be differentiated from deafness, mental retardation, developmental language disorder, aphonia, and the lack of understanding of a secondary language by recent immigrants. Panic disorder should be distinguished from substance-induced anxiety disorder (e.g., caffeinism), posttraumatic stress disorder, and medical disorders that cause anxiety (e.g., pheochromocytoma).

See Table 41–1 for the general and specific standard interviews and questionnaires useful in screening for and diagnosing anxiety disorders and phobias and in monitoring the treatment outcome of these disorders.

Anxiety disorders (particularly SAD) and depressive disorders frequently coincide. Anxiety disorders are also often encountered in children who have Attention-deficit hyperactivity disorder. Many children with one type of anxiety disorder have at least one other anxiety disorder (e.g., SAD with panic disorder, GAD, or avoidant personality disorder). The high degree of comorbidity may be explained on the basis of a risk hypothesis, on the basis of a hypothesis that there is a single underlying pathogenesis, or on the assumption that the symptoms of anxiety and depression overlap in a dimensional, noncategorical manner.

Treatment

Psychotherapeutic Interventions

Obsessive–compulsive disorder is the only anxiety disorder for which a best treatment can be recommended (see Chapter 24). With other anxiety disorders and phobias, it is reasonable to start with behavioral treatments and to try medication only if such treatments are unsuccessful. Family therapy, individual psychotherapy for unresolved conflict, and liaison with the patient's school are also commonly required.

The behavioral techniques most often used are systematic desensitization and exposure, operant conditioning, modeling, and cognitive-behavioral therapy (see Chapter 10).

Psychopharmacologic Interventions

Selective serotonin reuptake inhibitors (fluoxetine, fluvoxamine, paroxetine, and sertraline), the mixed serotonin and norepinephrine reuptake inhibitor (venlafaxine), tricyclic antidepressants and high-potency benzodiazepines (e.g., alprazolam, clonazepam) hold some promise in the treatment of anxiety disorders. Fluoxetine has been recommended for the treatment of social phobia. In non-OCD anxiety disorders in the pediatric age group involving more than 1,100 patients, the overall response rate was 69% (95% CI, 65–73%) in antidepressant-treated participants versus 39% (95% CI, 35–43%) in those receiving placebo. Four placebo-controlled studies have examined the effectiveness of tricyclic antidepressants in the treatment of SAD. In only one of these studies was the experimental drug more effective than placebo. One controlled study of the effectiveness of clonazepam in treating SAD showed no superiority over placebo. Controlled trials of clonazepam in treating GAD and social phobia showed no superiority over placebo. Fluvoxamine has shown superiority to placebo in the treatment of social phobia, GAD and SAD. There are no controlled studies of the effectiveness of medication in the treatment of juvenile panic disorder. β-Blockers have shown promise in the alleviation of examination performance anxiety in undergraduate students.

Complications/Adverse Outcomes of Treatment

The choice of treatment should be the result of a collaborative discussion between clinician, family, and patient. Presentation of data concerning age-specific benefits should allow for an informed evaluation of the potential benefits and risks of various treatments vs. no treatment and provide a framework for the comparison of drug vs. non-drug treatments.

The predominant adverse effects of antidepressants involve either central nervous system or the gastrointestinal tract. Central nervous system side effects include headache, nervousness, insomnia, drowsiness, anxiety, dizziness, fatigue, sedation, somnolence, mania, hypomania, and irritability. Selective serotonin reuptake inhibitors-associated behavioral activation (i.e., restlessness, hyperkinesis, hyperactivity, agitation) is 2–3-fold more prevalent in children compared to adolescents; it is more prevalent in adolescents compared to adults. Other side effects include sexual dysfunction in adolescent subjects.

The U. S. Food and Drug Administration as well as British and European regulators have issued public health advisories concerning the risk of suicide and self-harm associated with the use of antidepressant medication in the pediatric population. The magnitude of this risk is small, with these medications creating a 2-fold (4% vs. 2%) increased risk for “suicidal behavior or suicidal ideation.” There is a need for close monitoring. Recommended monitoring includes daily observation by caregivers, at least weekly face-to-face visits with patients or their family members or caregivers during the first 4 weeks of treatment, then every other week visits for the next 4 weeks, then at 12 weeks, and then as clinically indicated beyond 12 weeks. In addition, patients should also be monitored for associated behaviors (e.g., anxiety, agitation, panic attacks, insomnia, irritability, aggressiveness, impulsivity, akathisia, hypomania, mania). It is also clear that there is relatively little systematic data concerning the risks associated with the long-term use of these medications especially in young children.

Prognosis

The onset of SAD may be acute and precipitated by stress, or it may be gradual, without apparent precipitant. The prognosis is variable. Some children recover completely; others experience chronic or recurrent separation anxiety. These children are likely to relapse when their attachment relationships are threatened, even into maturity. Children with SAD are likely to develop panic disorder, agoraphobia, or depressive disorders in adolescence or adulthood.

The natural history of GAD is not understood. One study has shown that 65% of children diagnosed as having GAD or phobic disorder no longer carry the diagnosis after 2 years. Social phobia in childhood may become associated with alcohol abuse in adolescence. Most children with selective mutism “outgrow” it within a year of onset, although there may be residual shyness. In a minority of cases, mutism continues into late childhood or adolescence.