While we often think of childhood as a carefree time of life, children and adolescents do in fact experience high levels of stress and anxiety-sometimes on a debilitating scale. For the clinician addressing these issues, recognizing the varying types and causes of anxiety is only half the battle.
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of CME2, Inc. ("cme2") and Contemporary Pediatrics. cme2 is accredited by the ACCME to provide continuing medical education for physicians.
cme2 designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit™. Two credits will be awarded after the successful completion of both Parts I and II of this activity. Part II is scheduled to appear in the August 2007 issue of Contemporary Pediatrics.
Target audience: Pediatricians and primary care physicians
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Editors Toby Hindin, Jeannette Mallozzi, Jeff Ryan, and Karen Woldman disclose that they do not have any financial relationships with any manufacturer in this area of medicine.
Manuscript reviewers disclose that they do not have any financial relationships with any manufacturer in this area of medicine.
Authors Denise Bothe, MD, and Karen Olness, MD, disclose that they do not have any financial relationships with any manufacturer in this area of medicine.
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All children experience some level of anxiety in their lives. In infants, normal separation and stranger anxiety begins when the child starts to understand object permanence and form an attachment to their parents. Preschool-aged children, who are in the midst of learning the difference between fantasy and reality, typically experience anxiety/fear of the dark, monsters, and/or costumed characters. School-aged children and adolescents also go through anxiety-provoking stages as they begin to understand some of the realities of the world, which may be frightening or disappointing.
These feelings fall in line with the normal course of a child's development. But for some young children and adolescents, anxiety becomes part of their daily lives, robbing them of that precious carefree time of life. As primary care providers, pediatricians are poised to help these children achieve a healthier mental state-given the right knowledge.
Anxiety has been defined as a future-oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events, and a rapid shift in attention to the focus of potentially dangerous events or one's own affective response to these events.1 From the point of view of a small child, the feeling of being afraid and out of control is probably a more practical definition.
Classic reference sources such as The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provide the following definitions of anxiety disorders in children and adolescents:2
*Adapted from the DSM-IV (Text Revision), American Psychiatric Association, 1994
The American Academy of Pediatrics' manual on mental health disorders in children and adolescents (The Classification of Child and Adolescent Mental Diagnosis in Primary Care, Diagnostic and Statistical Manual for Primary Care [DSM-PC]3) goes further and lists anxiety disorders that do not meet criteria in the DSM-IV, but are nonetheless significant:
*Adapted from DSM-PC
Looking at the literature, the prevalence of children who suffer from anxiety complaints severe enough to interfere with daily life and functioning varies widely from 2.5% to 41%.4 This large variation in prevalence may be a reflection of the different methods employed in studies to diagnose anxiety in the children, or to variations in the numbers of stressors in different environments.
The most common anxiety disorders found among children are generalized anxiety, social phobia, and separation anxiety. As discussed earlier, generalized anxiety disorder (GAD) is defined as excessive anxiety and worry about events or situations during most days over a six-month period, coupled with impaired functioning. The excessive worrying characteristic of GAD occurs across a multitude of circumstances, such as school, sports, home, or social situations, and is associated with one or more of the following symptoms: irritability, muscle tension, sleep disturbance, restlessness, difficulty concentrating, and being easily fatigued. Other conditions, such as social anxiety disorder, have shown a lifetime prevalence of 12% and typically begin during the early teenage years.5 At the bottom of the spectrum is panic disorder, which has shown to have a very low prevalence in children.
Some overlap between anxiety and depressive disorders in children and adolescents has been found, but comorbidity rates vary greatly. One interesting finding is that there is a tendency for children with anxiety alone to be younger than children with depression alone.6 A few prospective studies also suggest that anxiety disorders in children are much more fluid than formerly believed. One study found that, over three to four years, 82% no longer met criteria for the original anxiety disorder at follow-up, but 15% of children were diagnosed with a different anxiety disorder, and an additional 13% shifted to a depressive diagnosis.7
Anxiety and depressive disorders have been referred to as internalizing disorders, and behavior disorders such as conduct disorders as externalizing disorders. However, there is limited evidence to support the clear differentiation between internalizing and externalizing disorders.
Comorbidities of anxiety and behavior disorders have also been reported, often with an overlap in symptoms. For example, some children with social phobia avoid situations that cause anxiety, which may be misinterpreted as oppositional behavior.8
Both genetic and environmental factors contribute to the development of anxiety. Although genetic factors may contribute to making a child more susceptible to anxiety, having a susceptibility doesn't mean one will develop anxiety. Environmental factors, such as a parent or caregiver's stress exposures, can also fuel a child's development of anxiety. Studies throughout the medical literature have demonstrated that children of anxious parents are more likely to develop an anxiety disorder than children of parents without anxiety.
Transitions in the lives of children, such as the start of daycare or school, can generate certain levels of anxiety as well. Most children recover from these typical transitions within a short period of time, but some will have persistent anxiety symptoms that may require intervention. Times of more significant stresses, such as a death in the family, violence, divorce, and/or natural disaster, may disrupt a child's life and sense of control to a great degree, thus creating anxiety.
Diagnosis of anxiety usually begins with a parent or caretaker's perception that a child is manifesting certain behaviors that seem abnormal, and they then seek help from their pediatrician. Common red flags can be seen below.9
*©worrywisekids.org, Tamar Chansky, PhD, 2007
Diagnostic procedures must take into account that there is significant comorbidity between pediatric bipolar disorder and anxiety disorders. Every child who has bipolar disorder should be evaluated by their pediatrician for the presence of comorbid anxiety disorders.10
Moreover, pediatricians should familiarize themselves with one or two anxiety-based screening scales (see Editor's note), recognizing that abnormal scores will require further diagnostic assessments. If a child's symptoms are abnormal in the context of the child's age and development, then referral to a therapist may be indicated for more extensive diagnosis and treatment.
Editor's Note: Look for "Worried sick: Anxiety among youth, Part II: Screening, treatment, and prevention" in the August 2007 issue.
1. Barlow DH: Anxiety and its disorders: The nature and treatment of anxiety and panic (ed. 2) New York, Guilford Press, 2002
2. Diagnostic and Statistical Manual of Mental Disorders, (ed. 4), Text Revision(DSM-IV-TR). Washington, D.C., American Psychiatric Association, 1994
3. Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. The classification of child and adolescent mental diagnoses in primary care. Wolraich ML, Felice ME, Drotar D (eds). Elk Grove Village, Ill., American Academy of Pediatrics,1996
4. Cartwright-Hatton S, McNicol K, Doubleday E: Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children. Clin Psychol Rev 2006;26:817
5. Schneier FR: Social Anxiety Disorder. N Eng J Med 2006;355:1029
6. Strauss CC, Last CG, Hersen M, et al: Association between anxiety and depression in children and adolescents with anxiety disorders. J Abnorm Child Psych 1988;16:57
7. Last CG, Perrin S, Hersen M, et al: A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 1996;35:1502
8. Schniering CA, Hudson JL, Rapee RM: Issues in the diagnosis and assessment of anxiety disorders in children and adolescents. Clinical Psych Review 2000;20:453
9. Chansky T, Siqueland L: Common red flags. Available at: www.worrywisekids.org. Accessed May 21, 2007
10. Wagner KD, Hirschfeld RM, Emslie GJ, et al: Validation of the mood disorder questionnaire for bipolar disorders in adolescents. J Clin Psychiatry 2006;67:827