Andres Martin, MD, MPH

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 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 

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 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).

 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 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.

 The Pediatric OCD Treatment Study (POTS) Team (2004) epidemiological data suggest that approximately one in 200 young people have obsessive-compulsive disorder (OCD). It may occur at any point throughout the life span. It can severely disrupt academic, social and vocational functioning. Among adults with OCD, one-third to one-half developed the disorder during childhood or adolescence, which suggests that early intervention may prevent long-term morbidity. The efficacy of pharmacotherapy with a serotonin reuptake inhibitor for pediatric OCD has been established for clomipramine (Anafranil), fluvoxamine (Luvox), sertraline (Zoloft) and fluoxetine. The pediatric literature is consistent with the adult literature in revealing a 30% to 40% reduction in OCD symptoms with pharmacotherapy, which still leaves the majority of patients who respond to medication management with clinically significant residual symptoms (POTS, 2004).

Prospective open-label studies also suggest the potential usefulness of cognitive-behavioral therapy (CBT) for pediatric OCD. One direct comparison of CBT versus clomipramine for pediatric OCD found an advantage for CBT. The results of the POTS (2004) study indicated that children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or with CBT alone. In a study examining the efficacy of group cognitive-behavioral therapy (GCBT) versus the use of sertraline in treatment-naive children and adolescents with OCD, it was found that GCBT may be effective in decreasing symptoms and should be considered as an alternative to either individual CBT or to medication such as sertraline (POTS, 2004).

Posttraumatic stress disorder/acute distress disorder.

 Posttraumatic stress disorder (PTSD) and acute stress disorder are a constellation of signs and symptoms that derive from extreme experiences that were actual or perceived threats of death or serious injury, either to oneself or to others. There is little empirical support for the use of pharmacotherapy in pediatric PTSD, consisting mostly of small case series or open trials.

For example, an open-label trial reported the use of transdermal clonidine (Catapres) as being effective for alleviating seven patients' symptoms, with the main adverse events being skin irritation and rebound hypertension. Similarly, relatively low doses of oral clonidine also have been shown to diminish hyperarousal and impulsivity symptoms in children and adolescents (De Bellis and Van Dillen, 2005). Guanfacine was reported as being helpful in a case report when used to treat nightmares of a 7-year-old patient (De Bellis and Van Dillen, 2005). The SSRIs frequently are used in children with PTSD, based on extrapolation from adult evidence. For example, citalopram (Celexa) was useful over eight weeks of open treatment (De Bellis and Van Dillen, 2005). The SSRIs also may be useful in youths with PTSD symptoms and comorbid depressive or panic symptoms. There is limited evidence to support the use of atypical antipsychotic agents in cases of pediatric PTSD (De Bellis and Van Dillen, 2005).

 Hallmark symptoms of GAD are broad-based and center on excessive worry and feelings that are difficult to control. The focus of the anxiety and worry is not as specific as in other anxiety disorders. Although studies have documented the safety and efficacy of benzodiazepines in adults, few studies have been conducted in the pediatric age group children with ADHD and comorbid anxiety (separation anxiety disorder, generalized anxiety disorder and/or social phobia) have a response rate to stimulants for ADHD that is comparable with that of children with general ADHD. The benefit of adding fluvoxamine to stimulants for anxiety remains unproven (Abikoff et al., 2005; RUPP Study Group, 2001; Walkup et al., 2002)

In a study done to assess the efficacy of and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder and/or social phobia, the authors found fluoxetine to be useful and well tolerated for the acute treatment of anxious youths (Birmaher et al., 2003). Often considered to have a mild side effect profile, an open trial of buspirone (BuSpar) in prepubertal children hospitalized with anxiety and aggression (n=25) documented agitation and manic symptoms in a significant number of treated subjects. The efficacy of the SSRIs and scant data supporting the use of buspirone argue against its use in pediatric anxiety (Reinblatt and Walkup, 2005).

Considerable advances have been made in the assessment and treatment of pediatric anxiety disorders. Strong relationships exist between pediatric anxiety disorders and various manifestations of adult psychopathology. Many of these disorders share a common thread and represent a developmental condition characterized by high levels of fear and apprehension. Despite the similarities of these varied disorders, advances in neuroscience will likely continue to assist in differentiating their unique symptom profiles and associated features. One area of research focuses on the amygdala and its role in aberrant processing of emotional information (Easter et al., 2005). There is a pressing need for better treatments for these often impairing conditions, and for comparison and combination studies of those currently available modalities that have proven effective.

Abikoff H, McGough J, Vitello B et al. (2005), Sequential pharmacotherapy for children with comorbid attention-deficit/hyperactivity and anxiety disorders. J Am Acad Child Adolesc Psychiatry 44(5):418-427.
 

Birmaher B, Axelson DA, Monk K et al. (2003), Fluoxetine for the treatment of childhood anxiety disorders: J Am Acad Child Adolesc Psychiatry 42(4):415-423.
 

De Bellis MD, Van Dillen T (2005), Childhood post-traumatic stress disorder: an overview. Child Adolesc Psychiatr Clin N Am 14(4):745-772.
 

Easter J, McClure EB, Monk CS et al. (2005), Emotion recognition deficits in pediatric anxiety disorders: implications for amygdala research. J Child Adolesc Psychopharmacol 15(4):563-570.
 

Pine DS, Klein RG, Mannuzza S et al. (2005), Face-emotion processing in offspring at risk for panic disorder. J Am Acad Child Adolesc Psychiatry 44(7):664-672.
 

Pediatric OCD Treatment Study (POTS) Team (2004), Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 292(16):1969-1976.
 

Reinblatt SP, Walkup JT (2005), Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am 14(4):877-908.
 

Research Unit on Pediatric Psychopharmacology (RUPP) Anxiety Study Group (2001), Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344(17):1279-1285 [see comments].
 

Varley CK, Smith CJ (2003), Anxiety disorders in the child and teen. Pediatr Clin North Am 50(5)1107-1138.
 

Walkup J, Labellarte M, Riddle MA et al. (2002), Treatment of pediatric anxiety disorders: an open-label extension of the research units on pediatric psychopharmacology anxiety study. J Child Adolesc Psychopharmacol 12(3):175-188.

Andres Martin, MD, MPH

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