Anxiety disorders are among the most common psychological disorders in younger patients, affecting 6% to 20% of US children and adolescents.1,2 Symptoms of withdrawal or inhibition can appear in children of preschool age, often leading to significant impairment in social and academic settings.3 Implications for adolescents and adults who have experienced anxiety during childhood include depression, substance abuse, and educational underachievement.4-7
Reduced access or lack of access to mental health specialists and the stigma associated with the use of mental health services increase the likelihood that anxious children will present in a primary care setting.8 These disorders often have distinct clinical presentations, and easily accessible diagnostic criteria should facilitate evaluation for childhood anxiety disorders during routine office visits. However, recently reported prevalence rates of childhood anxiety far exceed detection rates in primary care settings.9
This article describes common clinical presentations (see Table 110,11) and accepted diagnostic criteria for several anxiety disorders in pediatric patients, discusses screening strategies that may help identify problematic behaviors during the routine office visit, and reviews the significance of early treatment.
Patient History and Diagnostic Criteria
Childhood fear often represents a normal part of psychological development. In a healthy child, fear is usually temporary, proportional to the perceived threat, and resolved without intervention.12 Phobias, by contrast, represent a persistent and potentially debilitating preoccupation with a feared object or situation.9,12 The phobic child exposed to the source of his or her fear will avoid it, attempt to escape, or possibly experience an acute anxiety response—most commonly, freezing, clinging, crying, or exhibiting an angry outburst.9 Young patients with phobia may also complain of frequent stomach pain or headaches.6
Specific phobias, which are distinguished from social phobia or panic disorder, usually fall into one of four categories described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)10:
• The animal type of phobias, which is among the most common types found in children13 and may be transitory10
• The natural environment type, which includes fear of storms, heights, and darkness
• The blood-injection-injury type, encompassing fear of blood, injuries, or invasive medical or dental procedures
• The situational type, including fear of enclosed spaces, bridges, elevators, or flying.14
Specific phobias not addressed by one of these subtypes, such as a fear of sudden noises or of illness, are categorized as “other.”10 Importantly, diagnosis of a specific phobia disorder cannot be made without evidence that the condition has caused the child significant distress or disrupted daily activities for at least six months. According to DSM-IV diagnostic criteria, children need not recognize that their fear is inappropriate and excessive.10
Social phobia is typified by fear of unfamiliar or potentially embarrassing social situations.14 Common situations that incite moderate to severe fear in children with social anxiety disorder include speaking to an unfamiliar person, addressing an adult, initiating a conversation, and giving a public performance.15
Recently identified risk factors for social phobia include an association between child anxiety and maternal anxiety, although the researchers involved were unable to determine whether this correlation resulted from genetic transmission or parenting style.16 This study team also identified an increased risk for anxiety in children who displayed inhibited behavior (ie, those with a cautious, introverted temperament) or physiologic distress in new situations.
Another investigative group identified a correlation between behavioral inhibition and anxiety in children whose parents have panic disorder.17 The authors concluded that parental psychopathology and personal history of behavioral inhibition are indicators of a child’s increased risk for social anxiety disorder and warrant close monitoring.
DSM-IV diagnostic criteria specify that children must experience anxiety symptoms—possibly including “crying, tantrums, freezing, or shrinking from social situations with unfamiliar people”10—for at least six months to be diagnosed with social phobia. Symptoms occur in social settings involving peer groups. Children must be deemed capable of maintaining appropriate relationships with familiar persons.10
Separation Anxiety Disorder
Separation anxiety is the only anxiety disorder restricted to infancy, childhood, or adolescence.10 It is characterized by significant distress in a child who is separated from home or from his or her regular caregivers.
Children with separation anxiety disorder exhibit varying degrees of avoidant behavior that correlate with the severity of their symptoms.14 A child’s hesitation to fall asleep alone, for example, might represent a mildly avoidant behavior with nonconcerning symptoms. An occasional request to sleep with caregivers may illustrate moderately avoidant behavior and increasingly disruptive symptoms. Finally, a child’s inability to sleep anywhere but in the caregivers’ bed represents severely avoidant behavior and significant distress.14 While no widely recognized classification of such behaviors exists, a thorough history may help the primary care provider estimate the severity of a child’s distress.