Recognizing and treating childhood anxiety disorders.

Abstract

Childhood anxiety disorders are the most common type of psychiatric problemin children.1 Thesedisorders cause severe impairment and excessive distress. Although effectivepsychosocial and drug therapy exists, these anxious youngsters are virtuallyignored compared with children with other psychiatric problems. Few clinicallyanxious children come to the attention of physicians or other mental healthproviders.2 In 11 of 15 studies worldwide of impairing childhood anxiety disorders, theprevalence was greater than10%.3 In four offive large US surveys, prevalence was between 12% and20%.3 Otherpsychiatric problems are common in anxious children, particularly depression,behavior disorders, and substance misuse. Childhood anxiety disorderstypically onset in early childhood and follow a chronic and fluctuating courseinto adulthood.4 Although historically thought to be benign, these disorders can interferewith academic, social, and familyfunctioning.5 Theyare associated with an increased risk of failure in school and, in adulthood,low-paying jobs and financial dependence on welfare or other governmentsubsidies. Childhood anxiety is predictive of adult anxiety disorder, majordepression, suicide attempts, and psychiatrichospitalization.4,6 Children born to anxious parents are themselves more likely to be anxious.The mechanism for this association is unclear—both environmental(parenting style, parentchild interactions) and genetic factors have beenimplicated. Anxious parents may exacerbate their children's anxiety through aparticular style of interaction, including overprotection and excessivecontrol.7,8 Unfortunately, most children with anxiety disorders do not receive adequateassessment andtreatment.2 Thisfact is particularly disturbing because these disorders can be treatedeffectively with cognitive behaviortherapy9 and the useof selective serotonin reuptakeinhibitors.10 Why do practitioners neglect childhood anxiety? The reason may be a common,yet inaccurate, belief that anxiety in children and adolescents isdevelopmentally normal, typically transient, and innocuous. Terms such asfear, phobia, and anxiety are often used interchangeably among mental healthprofessionals and physicians, leading to diagnostic confusion andmisperceptions of the actual significance of anxiety disorders inchildhood.11 Fears are developmentally appropriate reactions to threats, which may beobjective (blood tests, tooth extractions) or subjective (strangers,lightning). During the first year of life, children typically fear intensestimuli, such as loud noises; potentially harmful stimuli, such as fallingover or strangers, and novel stimuli. Fears of tangible items (dogs, bodilyinjury) and vague objects (monsters, dark, separation) are most prevalentduring the preschool years (ages 1 to 4). During the school years, appropriatefears of evaluation, school-related events (tests, oral presentations), andaspects of peer relationships are most common. Phobias are different fromfears in that they are more persistent, disproportionate to the demands of thesituation, and impervious to reasoning. Phobias often occur outside the normaldevelopmental period during which fears occur (for example, a fear of the darkat age 15 instead of age 4). Anxiety is more diffuse, lacks specificity, andcan be thought of as a “state of apprehension withoutcause.”11 Although transient fears and anxieties are considered part of normaldevelopment, an anxiety disorder should be diagnosed if the anxiety becomes apersistent negative force in a child's life and cuases excessive distress orsignificant interference with school, peer involvement, autonomous activities,and/or family functioning. Separation anxiety disorder (excessive anxiety concerning separation fromhome or major attachment figures) and selective mutism (the persistent failureto speak in specific social situations despite speaking in other settings) arethe only anxiety-related diagnoses confined to childhood and adolescence bythe latest Diagnostic and Statistical Manual of Mental Disorders,4th edition (DSM-IV). For the remaining disorders (includinggeneralized anxiety disorder, social anxiety disorder, panic disorder with orwithout agoraphobia, obsessive-compulsive disorder, posttraumatic stressdisorder, and specific phobia), the manual's adult criteria are applied tochildren and adolescents. Because childhood fears and worries are variable, the assessment of ananxiety disorder in childhood requires paying attention to developmental,cognitive, socioemotional, and biological factors. Physicians and other mentalhealth providers require multisource (parent, child, and teacher) andmultimethod (rating scale, interview, and observational) data in order toascertain the presence of a disorder, to establish levels of current severityand impairment, and to identify appropriate targets for intervention. Whereas individual behavioral techniques, such as exposure and systematicdesensitization, can be effective for patients with simple phobias and otherless complicated clinical presentations, multicomponent cognitive-behavioraltreatment packages are the treatment of choice for most children with otheranxietydisorders.12 Thesetypically address the child's illness across many dimensions, includingsomatic (physical complaints), cognitive (biased thinking), and behavioral(clinging, crying, avoidance) problems. Results of controlled trials show thatcognitive behavior therapy can be effective in as many as 70% of clinicallyanxiouschildren.9,13Such therapy can be adapted for use in family, group, and school-basedintervention and prevention programs. Few high-quality studies have focused on effective drug treatments forchildhood anxiety disorders. The strongest research effort has been directedtoward the selective serotonin reuptakeinhibitors.11 Inthe RUPP Anxiety Study, a five-center trial initiated by the NationalInstitute of Mental Health, fluvoxamine was better than placebo when treatingpatients with separation anxiety disorder, social anxiety disorder, orgeneralized anxietydisorder.10 No goodevidence supports the use of tricyclic antidepressant or benzodiazapinemedication as a first-line treatment for suchdisorders,14 andmedication is often associated with sideeffects.15 Should cognitive behavior therapy or specific serotonin reuptake inhibitorsbe the first-line treatment? The National Institute of Mental Health recentlyfunded a large multicenter study (Child and Adolescent Multimodal TreatmentStudy) to address this issue. Meanwhile, cognitive behavior therapy should bethe treatment of choice. Despite dramatic gains in understanding the etiology and treatment ofchildhood anxiety disorders, far too few anxious children have benefited fromthese advances. Primary care physicians should take childhood anxietyseriously and promptly refer affected youngsters to specialists for furtherevaluation and effective treatment.