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Understanding Anxiety Disorders in Children and Adolescents: Brief Overview and Update

Understanding Anxiety Disorders in Children and Adolescents: Brief Overview and Update

Anxiety disorders are the most common mental conditions in the general population, including in children and adolescents. Young people can present with a pattern of anxiety symptoms somewhat different from that typically seen in adults. One of the most common aspects of this difference is that children (especially younger ones) may not report overt worries or fears, but instead manifest pronounced physical symptoms.

Separation Anxiety Disorder

Separation anxiety consists of excessive difficulties or protests about leaving home and loved ones, particularly parents. It usually will present in a pediatric office with school refusal or a wide variety of somatic complaints. It is helpful to obtain an early separation history, including whether the child could be left with relatives or other caretakers, and what early preschool or kindergarten separations were like. Sunday night and Monday morning "illnesses" are common telltale signs in these children, who often feel fine on Fridays and weekends. These children have a very difficult time going back to school after holiday breaks and especially after summer vacations.

Treatment usually consists of a behavior program set up in conjunction with parents, whereby the child is positively reinforced for tolerating progressively longer separations from their parents. Family and individual therapy are often utilized, but the evidence for their superiority over routine supportive therapy is not conclusive. There is robust evidence for the use of fluoxetine (Prozac) in the short-term treatment of anxiety disorders (separation anxiety disorder, generalized anxiety disorder and/or social phobia) (Birmaher et al., 2003; Varley and Smith, 2003). A listing of various anxiety disorders and their pharmacological treatments is given in the Table.

Specific Phobias

Specific phobias are marked by persistent fears that are excessive or unreasonable in reaction to specific objects or situations. They constitute the most common forms of anxiety disorders. An element common to all successful treatments for a specific phobia is persuading the patient to confront the phobic object or situation: the patient who fears flying must fly; the patient who fears closed spaces must spend time in them. The key is developing an appropriate set of graded exposure exercises and ensuring the patient's compliance with them.

Treatment is straightforward with easily manipulated phobic objects (e.g., dogs, snakes, spiders, heights, driving) and somewhat more challenging, but still quite feasible, with less easily controlled phobic cues (e.g., airplanes, storms). Traditionally, systematic desensitization has been employed, and there is now evidence that computer-generated virtual-reality exposure may also be effective. Recently, cognitive therapy has been successfully employed for specific phobias, which may be comparable in effectiveness to desensitization. Graduated in vivo exposure in combination with contingency management and self-control strategies appear to be the most promising treatment approaches to date. Drug treatment of specific phobia has not been extensively studied. In general, behavioral techniques are the first-line therapeutic intervention for most simple phobias.

Selective mutism. Selective mutism is the failure of the child to speak in social situations when the child has the capacity to speak and in the absence of an underlying language problem. Onset is typically in childhood. In a familiar setting, and in the company of familiar adults or family, the child may speak normally. In contrast, the child may be silent at school or other public settings. These youths are often painfully shy. The disorder cannot otherwise be explained by a developmental abnormality. There is a high rate of multiple anxiety disorders in the families of these youths. Behavior therapy appears effective, and treatment with fluoxetine seems modestly effective (Varley and Smith, 2003).

Panic disorder. Although panic disorder (PD) was thought to be rare in children and adolescents, the prevalence in community samples ranges between 0.5% and 5.0%, and in pediatric psychiatric clinics from 0.2% to as much as 10%. Psychoeducation and psychosocial treatments are recommended, and it appears that selective serotonin reuptake inhibitors are a safe and promising treatment for children and adolescents with PD.

One study tested the hypotheses that offspring of parents with panic disorder and offspring with anxiety disorders display relatively greater sensitivity and attention allocation to fear provocation (Pine et al., 2005). Results supported an association between parental panic disorder and offspring responses to fear provocation using computer-generated face viewing.

Agoraphobia, the fear of open or public places, is related to panic disorder and often is experienced as a fear of leaving the home. Agoraphobia is understood as developing in response to the fear of having a panic attack in a public place, or as having anxiety about being in places and situations from which escape might be difficult or embarrassing. Although agoraphobia can occur alone, it most often occurs in the presence of panic disorder (Varley and Smith, 2003).

Social phobia. Social phobia is manifested by a marked and persistent fear in one or more interpersonal or performance situations. This may be manifest as fear of rejection by peers, fear of public speaking or inability to use a public restroom. It is understood to be situationally bound to a social context. Medication (particularly the SSRIs) appears effective in treating social phobia over the short and long term, although this has yet to be established definitively in a pediatric population.


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