Introduction
After attention deficit hyperactivity disorder (ADHD) and conduct disorder, anxiety disorders are the most commonly observed psychiatric diseases in children and adolescents. Up to 10% of children and adolescents are affected by some kind of anxiety disorder (excluding obsessive-compulsive disorder – OCD – which affects up to 2% of children and adolescents – see chapter on OCD). More than 50% of anxious children will have a depressive episode as part of their anxiety disorder.Anxiety disorders in childhood and adolescence.
Except for posttraumatic stress disorder (PTSD), where an external traumatic factor is the primary cause, the major risk factor for childhood-onset anxiety disorder is having a parent with anxiety disorder or depression. Therefore, as with most psychiatric diseases, anxiety disorders are associated with brain development, with significant genetic contribution.Anxiety disorders in childhood and adolescence.
In children, emotional development influences the causes and the way fears and worries (normal or pathological) become apparent. Differently from adults, children might not recognize their fears as exaggerated or irrational, especially the younger ones.1,2
Both anxiety and fear are regarded as pathological if they are excessive, disproportionate to the stimulus, or qualitatively different from that observed at this age, and if they interfere with the child’s quality of life, emotional comfort or daily performance.3 Such exaggerated reactions to the anxiogenic stimulus commonly occur in individuals with inherited neurobiological susceptibility.Anxiety disorders in childhood and adolescence.
Although there is one clinical picture for each anxiety syndrome, most children will have more than one anxiety disorder. It is estimated that approximately 50% of children with anxiety disorders also have a comorbid anxiety disorder.Anxiety disorders in childhood and adolescence.
Epidemiology
Approximately 10% of all children and adolescents are estimated to meet the diagnostic criteria for at least one anxiety disorder.5 In children and adolescents, the most frequent conditions are separation anxiety disorder (SAD) with a prevalence around 4%,6 generalized anxiety disorder (GAD) (GAD; 2.7% to 4.6%) and specific phobias (2.4% to 3.3%).7,8 The prevalence of social phobia is around 1%7 and that of panic disorder (PD) 0.6%.Anxiety disorders in childhood and adolescence.
Gender distribution is equivalent, except for specific phobia, PTSD and PD, in which there is a female preponderance.1,2,8,9 SAD and specific phobias are more often diagnosed in children, whereas PD and social phobias are more common in adolescents.
If left untreated, anxiety disorders in childhood and adolescence (ADCA) have a chronic, albeit oscillating and episodic, course.Anxiety disorders in childhood and adolescence.
Course of ADCA
The various anxiety disorders in childhood and adolescence often develop during specific developmental stages. SAD is more common than GAD in younger children (6-8 years), whereas in adolescents, GAD is more frequent than SAD,11 being possibly correlated with levels of social maturity.12 ADCA may continue into adulthood. Childhood-onset SAD may precede PD and agoraphobia in adults.13 Adolescents with specific phobias are at a greater risk for specific phobias in adulthood, and adolescents with social phobias have a higher risk for social phobias in adulthood. Likewise, adolescents with GAD, PD or major depression are at a greater risk for developing these disorders, or their combination, in adulthood.Anxiety disorders in childhood and adolescence.
Clinical course and treatment
Evidence that some forms of childhood anxiety may be related to anxiety disorders in adulthood contributed to the development of specific diagnostic, treatment and prevention strategies for children and adolescents.15 Although the diagnostic methods for anxiety disorders in children are similar to those used in adults, the assessment and treatment of pathological anxiety in children have peculiar characteristics.Anxiety disorders in childhood and adolescence.
Most children with anxiety disorders are referred for mental health services due to behavioral problems related to their relationships and school environment. Given the major symptoms, clinicians have to understand these behaviors in a context of restrictions on normal development, which underlie these behaviors. Thus, it is possible to establish a hierarchy of differential diagnosis
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