Childhood Anxiety Disorder

Rick D'Alli, MD

In This Article

Abstract & Introduction


What is important to know about childhood anxiety disorders? Find out in these easy to read, clear descriptions with an introduction by guest editor Rick D'Alli, MD, and compiled by the editors at Medscape Psychiatry & Mental Health.


The Mask of Pediatric Anxiety

Seven-year-old Jay had a great first day of school. But when he woke up the next morning he was in a terribly irritable mood. Jay wasn't going to get ready for school that morning and his mother's 1 hour of cajoling, then bargaining, then demanding, and finally threatening hadn't changed his mind. In fact, Jay's irritability escalated into a raging, destructive tantrum, prompting his mother to put him in a "therapeutic hold," a maneuver she had been taught during one of Jay's previous psychiatric hospitalizations for out-of-control episodes.

On what should have been his third day of school, Jay and his parents came to see me for the first time on referral from a colleague. Jay clung to his mother, burying his head in her shoulder, stonewalling my attempts to get to know him. I encouraged his father to take Jay back into the waiting area to play, so I could give his mother my full attention. She spun a long, but familiar, tale of several previous encounters with mental health experts who had diagnosed Jay alternately with bipolar disorder, oppositional defiant disorder, and/or intermittent explosive disorder. Jay had also been treated, arguably only partially, with at least 1 representative of every major group of psychopharmacologic agents. None had proved effective.

After 20 minutes, I invited Jay and his father back into the office. I started with a little "goofing around," asking him about his age, favorite type of pizza, and most challenging video game, all the while offering preposterous guesses. Jay relaxed, laughed, and began to speak in a loud, boisterous, and precocious way. It took only a little more time for Jay to reveal that he was sure that some unthinkable disaster would befall his parents if he went off to school. As he released his grip on his mother, Jay became increasingly fidgety, then overtly hyperactive. His mother couldn't remember Jay's old kindergarten teacher ever mentioning inattention or off-task behavior, but she had clear memories of escalating tantrums, since Jay had started day care. When I asked about Jay having worries, his father's intense face became animated with expression.

Anxiety -- too often missed in children, often confused with other syndromes, and sometimes comorbid with other emotional problems -- manifests in a variety of forms, from primitive defiant, if not hyperaroused, states to withdrawn, regressed, even depressed-appearing states. Although the DSM-IV lists only separation anxiety disorder and selective mutism as anxious illnesses "first diagnosed in infancy, childhood or adolescence,"[1] children, including very young children, can and do suffer from every anxiety disorder formally described elsewhere in the psychiatric literature. Anxiety becomes a disorder when it impairs function. In Jay's case his functioning in the family and "on the job" (ie, going to school) was clearly impaired.

How Much Anxiety Is Found in Children?

Prevalence rates clearly depend on the specific disorder, age, gender, and sample characteristics, but in general, most pediatric anxiety disorder experts believe that about 10% of all children and adolescents will meet criteria at any given time for at least 1 anxiety disorder. Several lines of evidence have given rise to the notion that early enduring temperamental traits may be correlated with anxiety; for example, behaviorally inhibited children seem to be at greater risk for the development of an anxiety disorder and concomitant neurophysiologic aberrations. Other factors, such as genetic loading, attachments, social/environmental exposures, and biological/developmental events, modify the risk. Careful analyses of specific anxiety disorders in children yield surprisingly unimpressive gender differences. However, the story changes in adolescence, when rates of anxiety in girls are higher than those in boys, suggesting to some that puberty imparts a bit of "protection" from anxiety in boys. In general terms, separation anxiety and specific phobias are more commonly diagnosed in children, whereas panic disorder and social phobia (social anxiety disorder) show up more commonly in adolescence. It has only recently been appreciated that obsessive-compulsive disorder (OCD) has its onset in childhood, sometimes quite early, striking latency-age boys more often than girls. Selective mutism is now viewed as social phobia.[1]

Assessment of Anxiety in Children

Assessment of pediatric anxiety begins, as usual, with a thorough, multi-informant family, developmental, social, educational, medical and psychiatric history. One of the most critical goals is to distinguish anxiety from other psychiatric illnesses. Symptom overlap, such as that between anxiety and depression, complicates the effort. Too often the disruptive behaviors of the child with attention-deficit hyperactivity disorder (ADHD) or with oppositional and defiant disorder are confused with anxiety, and vice versa. Equally important to recognize is that significant comorbidity of discrete anxiety disorders with disruptive, mood, and substance abuse disorders commonly occurs in children and adolescents. Classic associations also provide clues, such as the common co-occurrence of OCD and Tourette's syndrome, or the emergence of posttraumatic stress disorder (PTSD) after trauma. There are a number of paper-and-pencil instruments with good reliability and validity that are currently available for assessing pediatric anxiety, but most are self-reports. Clinicians should always keep in mind that there is often a significant discrepancy between the report from a parent about anxiety symptoms in his or her child and that child's self-report. Many of the instruments cannot discriminate between state (a temporary condition) and trait (an enduring problem). Nevertheless, these instruments can be quite helpful when used as tools to screen for, support the diagnosis of, and track progress in the treatment of anxiety disorders.

Clinical trials are now demonstrating that children and adolescents respond to similar psychopharmacologic and psychotherapeutic strategies already developed for the treatment of anxiety disorders in adults. Until recently the number of published, rigorous studies in the treatment of pediatric anxiety was embarrassingly small, given its rather large prevalence. In general, it is becoming clear that the multimodal approach (ie, medication plus cognitive and/or dynamic psychotherapies plus parent/child education plus consultation to schools and pediatricians) is the best approach.

In summary, anxiety is a poorly appreciated, yet highly prevalent childhood illness. Untreated, it can rob a child of enriching family, social, and educational interactions, as it did for my new patient Jay. With school back in session, children and adolescents would be well served if primary care and mental health providers maintained a heightened index of suspicion about anxiety disorders among their pediatric patients.

Rick D'Alli, MD
Assistant Professor of Psychiatry
Division of Child and Adolescent Psychiatry
Johns Hopkins School of Medicine
Baltimore, Maryland


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