Childhood Anxiety Disorders

Recognition and Diagnosis in the Primary Care Setting

Lindsey Williams, MPA, PA-C, Catherine Pearman, MPAS, PA-C

Anxiety disorders are growing increasingly common among preadolescents. Children with anxiety at an early age often experience significant social and academic impairment. How can primary care providers become more adept in recognizing anxiety in their young patients?

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 1^10,11) 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

Specific Phobia
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
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 people¹⁰—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.

A DSM-IV–based diagnosis of separation anxiety disorder requires that the child exhibit at least three of the following symptoms for at least four weeks¹⁰:

• Clinically significant distress regarding the anticipated or actual separation from the home or from “major attachment figures” (ie, caregivers)

• Excessive fear of harm to caregivers

• Persistent worry about separating events, such as being kidnapped or getting lost

• Reluctance or refusal to leave home for any reason, including school

• Fear of being alone or without caregivers, at home or elsewhere

• Inability to sleep away from caregivers

• Frequent nightmares about separation

• Physical symptoms, such as headaches or nausea, prompted by anticipated or actual separation from caregivers.

Symptoms must be sufficiently severe to cause the child significant distress or interfere with school or other daily activities.¹⁰

Generalized Anxiety Disorder
“Overanxious disorder of childhood” is included in the DSM-IV description of generalized anxiety disorder (GAD), a condition of excessive, unfounded worry over numerous aspects of life.¹⁰ Among GAD-affected children are found several common characteristics, including self-consciousness, reassurance-seeking behavior,¹⁸ and preoccupation with punctuality, following rules, and maintaining a certain appearance; children are often overly mature for their age. Because of their perfectionist tendencies, these children may avoid challenging activities or public performances for fear of being judged incompetent or foolish.^10,11 Identifying GAD in children may be difficult, as many adults view their meticulous, submissive behaviors as advantageous traits.¹⁹

Natural disasters, physical attack, upcoming school-related events, and scapegoating by peers are the most common worries to affect children between ages seven and 12 who experience GAD.^11,20

For a diagnosis of GAD based on DSM-IV criteria, the patient must experience anxiety most days for at least six months, and the source of anxiety should be distinguishable from those associated with other anxiety disorders. The child must exhibit at least three of the following symptoms: restlessness, inclination to fatigue, difficulty concentrating, irritability, muscular tension, and sleep disturbances. Additionally, the child’s symptoms must be severe enough to disrupt daily activities or cause the patient significant psychological stress.¹⁰

Obsessive-Compulsive Disorder
Either obsessions or compulsions can satisfy a diagnosis of obsessive-compulsive disorder (OCD). Obsessions are recurring and irrepressible thoughts or impulses that may be illogical or unrelated to real-life problems but cause significant distress; compulsions are repetitive behaviors or mental acts performed to reduce anxiety or prevent a feared situation or event. Childhood OCD is more common among boys than girls.¹⁰

Children who have OCD are often affected by aggression obsessions (concerns about giving in to aggressive impulses, for example) and fear of catastrophic events.^21,22 Counting, checking, ordering, and washing in an effort to gain or maintain control are the most common compulsions seen in children and adolescents, but hoarding and saving compulsions are also prevalent, particularly among girls.^18,22

Children who meet the DSM-IV diagnostic criteria for OCD experience significant distress or impairment as a result of their symptoms. Devoting an hour or more each day to managing an obsession or compulsion is an essential feature of OCD. Unlike adults, who usually come to realize that their obsessions or compulsions are not reasonable, children with OCD often are not aware that they need help; usually their caregivers recognize the problem.¹⁰

Diagnostic Tools
In the primary care setting, open-ended questions about a child’s academic performance, social activities, and home life are easily incorporated in the history taking and may yield important information that indicates the need for further evaluation. A number of simple screening tools have been shown effective in identifying various anxiety disorders in the pediatric population. (See Table 2^23-25 for information regarding availability of these tests and instructions for scoring and interpretation.)

The Screen for Child Anxiety Related Emotional Disorders (SCARED),²³ a 41-item self-report questionnaire administered to both child and parent, has been shown effective in identifying pediatric anxiety disorders in both primary care and outpatient settings.^23,26 Both child and parent versions of the SCARED are available online.

The Multidimensional Anxiety Scale for Children (MASC)²⁴ is a 39-item instrument with both child and parent self-report components available for purchase. It has been successfully used in both clinical and community samples to screen for pediatric anxiety disorders.^24,27

The Pediatric Anxiety Rating Scale (PARS)²⁵ is a clinician-scored instrument that has been used to evaluate the severity of anxiety disorders in children.

Researchers conducting a comprehensive review of the most commonly cited and psychometrically valid anxiety scales used in children concluded that the PARS, combined with either the SCARED or the MASC, provided an appropriate assessment for pediatric anxiety disorders.²⁸

Treatment
Early detection of anxiety increases the patient’s likelihood of receiving early, effective treatment—which has been associated with short- and long-term success.^1,29

Research findings have supported the efficacy of cognitive behavioral therapy (CBT) in reducing anxiety symptoms and increasing function in anxious children.^30,31 In one study, anxious children who underwent CBT for primary anxiety disorders were found less likely than untreated children to engage in substance use during adolescence and young adulthood.³² This study also identified a slightly decreased incidence of chronic depression and anxiety in the treatment group.

For children with anxiety disorders, key components of CBT include acknowledging anxious feelings, clarifying thinking in situations that provoke anxiety, developing a plan for coping, and evaluating the effectiveness of the strategies used. Parental involvement appears to enhance CBT.^11,31

In other research, certain psychopharmacologic therapies have been shown to decrease anxiety symptoms in pediatric patients; the safety of these medications in children continues to be researched.^33-35 Combining CBT with pharmacotherapy has been associated with an improved response, compared with either treatment option alone.¹

In patients with a predisposition to anxiety disorders, such as children of a parent with a diagnosis of an anxiety disorder, preventive intervention strategies may also have a role.³⁶ Further study is needed to determine the most effective method for preventive intervention among higher-risk children. 

Conclusion
According to data from a growing body of evidence, anxiety disorders are disabling conditions that affect a significant portion of the pediatric population. Because children with anxiety will likely be seen in pediatric or family care practices, providers in these settings are called on to familiarize themselves with the signs and symptoms of common anxiety disorders, their diagnostic criteria, and the simple screening tools that are available. Accelerating patients’ access to available mental health services can help the provider prevent significant impairment in these children’s lives.

References
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