Anxiety in the Age of Innocence
Children and Anxiety Disorders
By Stephanie Sampson
When her oldest daughter starting having headaches, stomachaches, and lost interest in favorite activities, her mother was concerned that the eight-year-old had a serious physical problem. 

"I never thought about her having an anxiety disorder.  All I saw were the physical symptoms and the radical changes in her behavior," says Debbie P, whose daughter was eventually diagnosed with depression and generalized anxiety disorder (GAD). "All the acting out at school, the refusal to compete in soccer, the sleeping problems.I didn't know how much she was worrying and how anxious and depressed she really was." This mother's experience is typical, according to experts.  "Kids often suffer in silence with anxiety disorders," says Susan Swedo, M.D, Chief, Pediatrics and Development Neuropsychiatry Branch, National Institute of Mental Health (NIMH).  "Children don't understand why they worry or where the anxiety is coming from.  They can't give their anxiety a voice."   Instead, what parents see are behavior changes-ranging from extreme shyness to irritability and defiance.

An Age of Anxiety
Many children have some apprehension or fear about growing up-separating from parents, developing peer relationships, and attending school.  However, for a substantial group of children, anxiety about some of these issues becomes severe and long-lasting enough to affect a child's ability to conduct daily activities, perform in school or develop relationships.  "Anxiety disorders are among the most common psychiatric disorder in kids and often cause tremendous emotional pain and disruption of family life," says Daniel S. Pine, M.D., Chief, Section on Developmental and Affective Neuroscience, NIMH. "And we know that childhood anxiety disorders, if left untreated, can set the stage for more serious psychiatric illness in adolescence and adulthood." As many as one in eight children aged 9-17 may suffer from an anxiety disorder each year, according to the U.S. Surgeon General (see table).  Different anxiety disorders begin at different ages.  Some studies also indicate that, as the child gets older, these disorders may follow a "developmental progression" from one anxiety disorder into another and from an anxiety to an affective disorder. 

Prevalence of Childhood Psychiatric Disorders

Disorder

Six-month Prevalence

(in %)

Anxiety Disorders

13.0

Mood Disorders

  6.2

Disruptive Disorders

10.3

Substance Use Disorders                          

  2.0

Any Disorder               

20.9
Source:  Mental Health: A Report of the  Surgeon General (U.S. Department of Health and Human Services, 1999).

As in adults, anxiety disorders in youngsters co-occur with other psychiatric disorders. Up to three-quarters of children with an anxiety disorder suffer from another anxiety disorder or depression.  GAD in youngsters co-occurs the most frequently with other disorders; about one-half to three-quarters of children with GAD also have depression or another anxiety disorder such as separation anxiety disorder. Anxiety disorders may also co-occur with attention deficit hyperactivity disorder (ADHD) and Tourette's Syndrome.

Risk Factors
What makes a child prone to developing an anxiety disorder?  Researchers have yet to find "the" answer, according to Pine.  "Anxiety becomes a disorder when there's a mismatch between the inherent threat of a situation and the child's physical or emotional response that results in either suffering or impairment.  Many different things can influence that response, from brain chemistry to personality to things in the environment. " Gender, age and family history are known to influence the likelihood of developing an anxiety disorder.  Girls have higher rates of anxiety disorders than boys, a relationship that holds up into adulthood.  Different anxiety disorders also show up at different ages, with separation anxiety disorder common in very young children, social anxiety disorder beginning in early adolescence, and panic disorder in later adolescence and early adulthood.  Family history may also play a role.   "Having a parent with an anxiety disorder increases the chances of having a child with an anxiety disorder," says Kathleen Merikangas, Chief, Section on Developmental Genetic Epidemiology, NIMH.  "For all anxiety disorders taken together, a child whose parent has an anxiety disorder is three-and-a-half times more likely also to have an anxiety disorder than a child whose parent does not have one," she says.  For example, about one in four children with obsessive compulsive disorder (OCD) has a family member with OCD; almost all the remaining three-quarters have a relative with another anxiety disorder or an affective disorder.   Other factors being studied include a child's temperament and personality.  For example, temperament may affect how sensitive a child is to new situations or stimuli and whether a child misinterprets normal bodily sensations associated with fear and anxiety (increased pulse rate or sweating) as indicators that something "bad" will happen.  "Some children are more predisposed to respond with more fear or anxiety to certain situations," says Merikangas. "But every child with fears need not develop an anxiety disorder."  She counsels parents to acknowledge and accept their child's temperament and work with teachers and other adults to give the more reactive child specific ways to deal with-and eventually overcome-their fears. Merikangas is currently analyzing 10-year follow-up data to see what, if any, factors in early childhood may lead to the development of anxiety disorders in adolescence and early adulthood.  Her study is the first to track factors such as gender, childhood illnesses, parental health status and neurological, neuropsychological and psycho physiologic function (including the startle reflex) over the long term.  The research was conducted with 203 children aged 7-17 in 1989 and followed up in 1999 with the same group, then aged 17 to 27.Experts caution parents not to blame themselves or the child for the disorder. "Anxiety disorders, like other psychiatric disorders, are complex.  It's the combination of factors that appears more important that just one alone," says Pine.

Treatment
Over the last two decades, researchers have confirmed the effectiveness of both medication and psycho-social therapies for childhood anxiety disorders.  Psychosocial therapies are often the first step in treating young patients.  These include psychotherapy (such as "talking," play, or art therapy), behavioral therapies (such as exposure therapy) and family therapy

Is It “Just a Phase?”Every child is worried about something at some time in his or her life, many are shy, and many like routines and rituals as part of their daily life. To distinguish what may be “just a phase” and what might be an anxiety disorder, Susan Swedo, M.D., recommends that parents keep in mind three things: Duration of symptoms. Keep track of how long symptoms last. In a phase, the behavior is usually there only a small part of the time, while the symptoms of an anxiety disorder are more persistent and occupy the majority of a child’s waking hours.Duress. Listen for complaints about how your child’s symptoms cause her stress. For example, she may be bothered by not having any friends or be tired of having to wash her hands all the time. Difficulties. Assess how much the symptoms interfere with the child’s life, keeping him from accomplishing tasks or fulfilling his responsibilities at school or home. Also try to judge whether the child is performing at expected levels for his capabilities.

Research shows that the psychological therapies appear to have long-lasting effects and help prevent relapse.  Through them, children develop coping skills and "re-learn" their response to anxiety-producing situations-skills that can be used in different situations.  In addition, such therapies have no side effects.  However, patients and their families must be willing to stay with the program over a period of time (usually several months) in order to see any improvement.

 Prescription drugs can have a rapid and positive effect on a child's anxiety and depression, but as with all medicines they must be used with caution and monitored for side effects.  Two classes of anti-depressants-selective serotonin reuptake inhibitors (SSRIs) and tricyclics-are used to treat pediatric anxiety disorders.  Anti-anxiety drugs, such as alprazolam, may also be prescribed. 

Both approaches have their advantages, and parents may find that their child's doctor recommends beginning with one kind of treatment, then switching or combining treatments. 

For example, OCD treatment guidelines recommend starting with cognitive-behavioral therapy (CBT); treatment may begin with medication for the severely ill patient.  "Medication [usually an SSRI] is effective to get an immediate reduction of symptoms." said John March, M.D., M.P.H., Department of Psychiatry, Duke University Medical Center, Durham, NC.  "However, its effects only last as long as the patient takes the drug.  Research shows that combination therapies or CBT alone have longer lasting effects and help prevent relapse."

For social anxiety disorder, both kinds of treatment appear to be effective when used alone, although little research exists on combination therapies.  "We have found that improving kids' social skills, exposing them to the social situations that they fear, and then giving them a chance to practice those skills with their peers results in less anxiety, " said Deborah C. Beidel, Ph.D., Department of  Psychology, University of Maryland, College Park, MD.   A recent large-scale clinical trial has shown that the SSRI fluvoxamine is effective in reducing symptoms in youngsters with social anxiety, separation anxiety and GAD.

Despite the prevalence of anxiety disorders in youth, these disorders remain vastly understudied, according to Beidel, who serves as the chair of ADAA's Children's Task Force.  A literature review conducted in 1998 revealed that only 15 controlled trials had been conducted on pediatric anxiety disorders (see monograph, Conference on Treating Anxiety Disorders in Youth: Current Problems and Future Solutions," available from ADAA).

Fortunately, the pace of research is picking up. Researchers are continuing to study the effectiveness of SSRIs, compare different therapy combinations for both OCD and non-OCD anxiety disorders, and explore treatment strategies for comorbid disorders such as ADHD.

What Parents Can Do"It was totally exhausting and baffling to deal with a child who is bright but whose behavior just seemed out of control," says Debbie P., the mother mentioned earlier.  Once the diagnosis of GAD was made, a psychiatrist prescribed an SSRI and psychotherapy.  "Things are going better for our daughter.  She says she feels better and she is performing better in school.  And as parents, we're getting better about recognizing the kinds of situations that make our daughter anxious and better in helping her cope with them."

Parents who suspect something is wrong need to push to get their child help. The table below summarizes symptoms for the more common anxiety disorders of childhood.  

"An anxiety disorder was not among my first diagnostic considerations as a practicing pediatrician," admits Swedo, although she that believes family doctors and pediatricians are becoming more aware of these disorders. "Parents should go in armed with a record of their child's behavior and ask for a referral to a mental health professional."  School systems and county health departments also offer free psychological testing, she says.

Generalized Anxiety Disorder

Social Anxiety Disorder

Obsessive-Compulsive Disorder

Excessive worries about a wide variety of subjects

Marked and persistent fear of one or more social situations (such as oral presentations or plays)

Excessive worries about dirt, germs or other dangers; may repeat same questions over and over or constantly seek reassurance

Worries cause the child to be anxious, nervous or tense much of the time

Anxiety, tension or "freezing" in response to certain social situations

Engages in ritual/repetitive handwashing, bathing, cleaning, checking, arranging or counting. 

Child tries to stop worrying but can't control the anxiety; worries interfere with friends, school or home life

Fears interfere with daily activities and/or peer relationships

Worries or behaviors interfere with friends, school, home life

Worries present for at least 6 months

Fear of social situations lasts at least 6 months

Obsessive-compulsive symptoms for more than an hour each day; experiences symptoms as unwanted and intrusive

Exhibits least one physical symptom, such as restlessness, feeling keyed up or "on edge;" fatigue; difficulty concentrating; irritability; muscle tension; or sleep problems

Has physical symptoms of anxiety (sweating, blushing, racing heart, trembling) when confronted with certain social situations

Source:  Swedo, Susan and Leonard, Henrietta,  Is It "Just a Phase"  (Golden Books, New York, 1998).

This article is reprinted from the Anxiety Disorders Association of America's bimonthly newsletter, the Reporter.  If you would like to subscribe, please visit our website at www.adaa.org, click on "Consumer Resources" and go to "Supporter Subscriber", or call the ADAA at 301-231-9350.