The last few years have brought exciting breakthroughs in the area of anxiety disorders in youth. Anxiety disorders in children and adolescents has been recognized as one of the most common areas of pediatric psychopathology. These advances are of great importance because anxiety disorders in children are associated with negative outcomes including peer relationship difficulties, academic failure, and later onset of comorbid disorders including major depression and alcohol abuse.
Normative data about anxiety symptoms in the general population are now available. These findings are helpful to the clinician in differentiating "normal" childhood worries from clinical worries. Subclinical anxiety symptoms are very common in the general pediatric population. About 70% of grade school children report they worry "every now and then".1 The most common worries are related to school performance, illness of self or others, getting teased, making mistakes, or concern about physical appearance. Children with generalized anxiety disorder (GAD) compared to normal children describe a greater number of more severe, impairing worries. Children with GAD have trouble controlling their worry and do not participate in activities to distract them from their worried thoughts. Interestingly, some normal children, unlike those with GAD, recognize their main worry as serving a positive purpose.1 For example, the worry may help them work harder at school or prepare more diligently for exams.
A number of factors have been identified as contributing to the etiology of anxiety disorders in children. These factors include genetics/temperament, mother-child attachment pattern, presence of parental psychopathology, and parenting style. Behavioral inhibition in young children, characterized as persistent, fearful, avoidant behavior in response to new situations and novel stimuli, increases the likelihood of later developing anxiety disorders, especially social phobia in adolescence.2 Insecure mother-child attachment pattern has been linked to subsequent onset of anxiety.3 In addition, offspring of parents with anxiety disorders and of parents who exhibit a controlling, overprotective parenting style are more likely to manifest anxiety disorders themselves.4 Future research that investigates the interplay of these etiological factors will serve to identify which children are at risk for anxiety.
The treatment advances have been dramatic! Studies document that individual cognitive-behavioral therapy (CBT) and group CBT are efficacious in treating youth with separation anxiety disorder, social phobia, and/or GAD.5 In the arena of psychopharmacology, selective serotonin reuptake inhibitors (SSRIs) have been shown to have short-term efficacy and safety in the treatment of childhood anxiety disorders.6-7 The Research Unit on Pediatric Psychopharmacology (RUPP) Anxiety Study Group demonstrated that 8 weeks of fluvoxamine was significantly more efficacious than 8 weeks of placebo in reducing the severity of clinician-rated anxiety and in producing improvement on a clinician-rated scale of global change.6 The SSRI was generally well tolerated, although it was associated with significantly more stomachaches and a trend toward greater motor activity than placebo. Thus, evidence-based treatments are available for children with anxiety disorders. In clinical practice, combined treatments are often used to target severe, impairing anxiety symptoms. Direct comparison of CBT, SSRI, CBT plus SSRI, and a control condition will determine if combined treatment provides additional benefit over a single intervention (i.e. CBT or SSRI).
Early identification and intervention is an important area of investigation. An early intervention project in Australia compared group CBT versus monitoring for children with mild-moderate anxiety disorders and for those with subthreshold anxiety disorders.8 Group CBT decreased the prevalence of anxiety diagnoses posttreatment, and also prevented the onset of new anxiety disorders over time. At 6-month follow-up, only 16% of children who received the group intervention had the onset of a new anxiety disorder compared with 54% in the monitoring group.8 Hopefully, early intervention will prevent negative outcomes associated with untreated anxiety. Prospective studies of treated and untreated children will address this issue.
The future directions in anxiety research are numerous. This burgeoning field needs new researchers. Since academic child and adolescent anxiety psychiatry offers a lifestyle with variety, flexibility, challenge, and innovation, I strongly recommend an academic career that includes research. Linking neuroscience, genetics, behavioral science, and epidemiology will advance our knowledge of etiology, risk, and protective processes in early-onset mental illnesses and will guide our treatment approaches.9 Translational research that incorporates basic science findings in designing real-life interventions is a crucial area of investigation. It is important that basic science findings, developmental theory, and conceptual models guide child and adolescent psychiatry research.9
Gail A. Bernstein, M.D.
Endowed Professor in Child & Adolescent Anxiety Disorders Head, Program in Child & Adolescent Anxiety & Mood Disorders University of Minnesota Medical School, Minneapolis, MN
- Muris P, Meesters C, Merckelbach H, et al: Worry in normal children. J Am Acad Child Adolesc Psychiatry 37:703-720, 1998
- Kagan J, Snidman N: Early childhood predictors of adult anxiety disorders. Biol Psychiatry 46:1536-1541, 1999
- Warren SL, Huston L, Egeland B, et al: Child and adolescent anxiety disorders and early attachment. J Am Acad Child Adolesc Psychiatry 36:637-644, 1997
- Siqueland L, Kendall PC, Steinberg L: Anxiety in children: perceived family environments and observed family interaction. J Clin Child Psychol 25:225-237, 1996
- Flannery-Schroeder EC, Kendall PC: Group and individual cognitive-behavioral treatments for youth with anxiety disorders: a randomized clinical trial. Cognitive Ther Res 24:251-278, 2000
- RUPP Anxiety Study Group: Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344:1279-1285, 2001
- Rynn MA, Sigueland L, Rickels K: Placebo-controlled trial of sertraline in the treatment of children with generalized anxiety disorder. Am J Psychiatry 158:2008-2014, 2001
- Dadds MR, Spence SH, Holland DE, et al: Prevention and early intervention for anxiety disorders: a controlled trial. J Consul Clin Psychol 65:627-635, 1997
- National Advisory Mental Health Council's Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment: Blueprint for Change: Research on Child and Adolescent Mental Health - Executive Summary and Recommendations, Washington DC, 2001