Anxiety Disorders in Children and Adolescents

Epidemiology, Risk Factors and Treatment

Cecilia A. Essau, Franz Petermann, Cecilia A. Essau, Franz Petermann

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134945214
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Recent years have seen a growing awareness of the common occurrence of anxiety disorders in children and adolescents. There has been a parallel increase in the number of studies examining the risk factors, comorbidity, course and outcome of such disorders, as well as the developments of numerous preventative and intervention strategies.
The aim of Anxiety Disorders in Children and Adolescents is to present a comprehensive summary of the most recent empirical findings in this area. Written by eminent researchers and clinicians from Europe and America, the book is divided into three broad sections. The first provides a general overview of anxiety disorders in the young, outlining classification and assessment strategies as well as research methods and design. Part two contains chapters on the seven subtypes of anxiety disorder, including panic disorder, obsessive-compulsive disorder and posttraumatic stress disorder. The final section deals with the progress that has been made in the understanding of such disorders and provides recommendations for future investigation.
Anxiety Disorders in Children and Adolescents is intended for students, researchers and other professionals in the fields of psychology, psychiatry, pediatrics and social work.

PART I

GENERAL ISSUES

1	FEARS, WORRIES, AND ANXIETY IN CHILDREN AND ADOLESCENTS

Thomas H. Ollendick
Amie E. Grills
Kemie L. Alexander

Although terms such as fear, worry, and anxiety are often used interchangeably, a clear distinction among them can be seen in the empirical literature. At the most basic level, this distinction lies in the definitions and descriptions of these phenomena. For instance, fear has been described as a reaction to accurately perceived dangers that are associated with unpleasant feelings (Erol and Sahin, 1995; Marks, 1987a). More broadly, fear can be defined as a painful feeling of impending danger when confronted by life-threatening dangers. In contrast, worry has been characterized as anxiety-related thought processes (Borkovec et al., 1983). Worry is generally considered to be a cognitive component of anxiety, involving uncontrollable negative thoughts about future events. Thus, the primary difference between these two anxiety-related phenomena is that fear occurs in the presence of an actual threatening stimulus, whereas worry pertains to future-oriented thoughts about the threatening stimulus, but in the absence of that stimulus (Muris et al., 2000). Finally, anxiety has been conceptualized as a more global term that encompasses physiological tension and arousal, cognitions of threat, and behavioural avoidance (Hagopian and Ollendick, 1997). Clearly the anxiety response has adaptive value when an individual is actually confronted by dangerous stimuli. However, when this reaction occurs in response to an unreasonably perceived danger or with excessive intensity, thus causing impairment to the individual, an anxiety disorder is said to exist.

Despite definitional distinctions among fear, worry, and anxiety, questions regarding what differentiates normal and pathological variants of these emotional states remain. For instance, worry has been described as a component of a number of classifiable anxiety disorders. For example, excessive worry is the essential feature of generalized anxiety disorder and worry about separation from a primary caregiver is the core feature of separation anxiety disorder. Moreover, fear of particular stimuli is clearly the major symptom of specific phobias. Still, both worry and fear characterize social phobia. Further complicating this issue is the fact that researchers continually use these terms interchangeably in both research studies and scale development without clearly distinguishing their intended meaning.

Despite the controversy over the use of anxiety related terms, researchers in the past several years have become increasingly interested in the specific aspects of each of these three overlapping, yet relatively discrete, areas of study. Research within the first two of these areas (i.e., fear and worry) has been primarily focused on their prevalence and expression in normal children. In contrast, the majority of empirical studies regarding anxiety disorders has been conducted using clinic referred samples. Nevertheless, there exists a growing body of literature that has also examined anxiety at the symptom, as opposed to the syndromal, level.

For example, anxiety is commonly depicted as either reflecting state or trait characteristics. State anxiety has been defined by Spielberger (1975) as a reaction, “consisting of unpleasant consciously-perceived feelings of tension and apprehension, with associated activation of the autonomic nervous system” (pp. 115–143). On the other hand, trait anxiety has been described as a general anxiety-proneness that is a characteristic of an individual's general disposition or personality. Regardless of the individual's age, most studies have examined relationships solely between psychopathology and anxiety-proneness or trait anxiety (Comunian, 1989; Maddux and Stanley, 1986; Messer and Beidel, 1993). Nevertheless, research with adults (Hodges and Felling, 1970) as well as children (Gaudry and Poole, 1972) has demonstrated that those with high trait anxiety levels react to evaluative situations with higher degrees of state anxiety than those with low trait anxiety. This suggests that these two aspects of anxiety are related and that state anxiety might be more easily activated in those individuals high in trait anxiety and predisposed to react in an anxious manner.

Thus, researchers who are interested in anxiety at the symptom level have generally embraced more of a dimensional scheme, where a continuum from normal to clinically impairing anxiety is described. Thus, similar to fear and worry, there also exists research on the prevalence and appearance of anxiety symptomology in normal children.

Fears in Normal Children

Most children experience some degree of fear throughout the course of their development. In fact, one recent study of 190 normal children between 4 and 12 years of age from the Netherlands found that 75.8% reported being fearful of at least one stimulus (Muris et al., 2000) and a majority of these children were fearful of multiple stimuli. Nevertheless, childhood fears generally tend to be mild, age-related, and transitory despite variance in their frequency, intensity, and duration (Hagopian and Ollendick, 1993; Marks, 1987b; Ollendick et al., 1994a). This notion can be illustrated through delineation of the typical developmental pattern of fears in children. For most children the initial experience of a fearful reaction occurs during infancy when a loud noise or loss of support produces a startle-response. Following this, an increased paniclike fear tends to result in older infants when they are exposed to new situations, unfamiliar people, or separation from major attachment figures. Later, children between the ages of two and four begin to develop fears of imaginary creatures (i.e., ghosts, monsters) as well as animals and the dark. School-related fears tend to appear shortly after this when the child first enters formal schooling. These fears may also reappear if changes in schools or grades (i.e., a move into middle school) occur. Finally, during adolescence, the primary fear is commonly related to social and evaluative concerns (i.e., embarrassment in front of peers; Ollendick and Vasey, 1999).

This fairly specific developmental pattern has been demonstrated in several studies of childhood fears. For example, Bauer (1976) divided children into three age groups (e.g., 4–6, 6–8, 10–12) and found that 74% of the youngest group of children reported fears of ghosts and monsters, as compared to 53% of the 6–8 year olds and only 5% of the 10–12 year olds. Conversely, only 11% of the youngest group of children reported fears of bodily injury or physical danger as compared with 53% and 55% of the two older groups of children. More recently, Muris et al. (2000) found similar findings in their study of normal children. These researchers reported findings regarding the top three fears indicated by children in age groups of 4–6, 7–9, and 10–12 years of age. For children in all three of these age groups the most frequently reported feared stimuli were animals. However, the next most frequently reported fear among the 4–6 and 7–9 year olds was imaginary creatures, whereas for the 10–12 year olds it was social threats. Finally, the third most frequently reported fears were environmental threats (4–6 year olds), frightening dreams/movies (7–9 year olds), and being kidnapped (10–12 year olds). Thus, similar to the results of Bauer, the fears reported by children in this study also appear to follow a developmental pattern. Regardless of developmental age, it appears that children's fears are consistently related to harm coming to themselves. It appears that as children grow to recognize the “imaginary” nature of their earlier fears of harm, these fears do not completely dissipate but instead transfer to other more age appropriate stimuli.

The prevalence of fears also appears to change with age and gender. For instance, whereas the overall prevalence of fears in the Muris et al. (2000) study was 75.8%, significant age differences also emerged. These findings revealed that fears were most commonly reported by seven to nine year olds (87%), followed by 4–6 year olds (71%), and finally 10–12 year olds (67.8%). Furthermore, girls in this study reported a significantly greater percentage of fears regarding being kidnapped whereas boys tended to report more fears about imaginary creatures. This finding is consistent with other researchers who have found that girls tend to report significantly more fears than boys. For instance, Ollendick and colleagues have repeatedly found that girls report a greater level and number of fears as compared to boys (King et al., 1989; Ollendick et al., 1989, 1996; Ollendick and Yule, 1990).

One of the major advances for the study of childhood fears occurred with Ollendick's (1983) revision of the Fear Survey Schedule for Children (Scherer and Nakamura, 1968). The Revised Fear Survey Schedule for Children (FSSC-R) has proved to be one of the most commonly used measures in the study of anxiety related phenomena. The numerous studies utilizing this measure have provided a rich body of literature from samples within the United States as well as a number of other countries. For example, studies conducted in Australia, Belgium, China, Great Britain, Holland, Kenya, Nigeria, and Turkey have provided information on cultural norms as well as cross-cultural differences. Although distinct cultural and environmental experiences can be expected to influence children's fears, studies utilizing this measure in different countries have consistently revealed similar findings regarding the types of fears reported. In line with the previous description of the developmental pattern of fears, the most frequently endorsed fears in all countries tend to be related to physical harm and dangerous situations (Dong et al., 1994; Erol and Sahin, 1995; Ingman et al., 1999; Muris et al., 1997a, 1997b, 2000; Ollendick et al., 1985, 1989, 1991, 1996). For example, Ollendick et al. (1985) found the 10 most commonly rated fears in an American sample of children aged 7–18 to be being hit by a car or truck (42%), not being able to breathe (38%), fire or getting burned (38%), death or dead people (36%), bombing attacks or being invaded (34%), getting poor grades (34%), a burglar breaking into your house (33%), having my parents argue (33%), looking foolish (31%), falling from high places (30%), and being sent to the principal (30%). In addition to these, other commonly reported fears have included illness, earthquakes, spiders, and snakes (Muris et al., 1997a). Although these percentages clearly reflect fears of harmful acts occurring to oneself, there are also school related and familial fears interspersed.

Furthermore, another group of researchers has examined the utility of the FSSC-R with regard to diagnostic differentiation, particularly among subtypes of specific phobia (Weems et al., 1999). These researchers investigated the utility of the FSSC-R subscales in a sample of 120 clinically phobic children and their parents. The primary purpose of the study was to determine whether children's or parent's reports on this measure could be used to differentiate among children diagnosed with social phobia, specific phobia of the dark/sleeping alone, specific phobia of animals, or specific phobia of shots/doctors. The results of this study revealed that both children's and parents’ reports could discriminate among the specific phobias. In addition, parent reports were found to distinguish among the specific and social phobias. These findings suggest that specific phobias in clinically referred children are similar to those reported by normal children. However, in phobic children the severity of these fears/phobias is significantly greater.

Worries in Normal Children

In contrast to the vast amount of research that has examined childhood fears, few empirical studies of worry in children have been conducted. Nevertheless, from these studies a number of similarities regarding worries and fears in normal children have become evident. In particular, these studies have revealed similar prevalence rates, content of worries, developmental patterns, and gender differences.

To begin, consistently high prevalence rates have been reported for childhood worries. Regarding the overall number of worries reported by children, Orton (1982) reported that more than 70% of primary school children reported 10 or more things about which they worried. Similarly, Silverman et al. (1995) found children aged 7–12 reported an average of 7.64 different worries. Furthermore, Muris et al. (2000) noted that 67.4% of their overall sample of children reported at least one worry. Finally, Bell-Dolan et al. (1990) reported that up to 30% of normal children in their sample (aged 5–19) exhibited subclinical levels of excessive worry. Thus, as has been reported with fears, worries are also common in normal children.

Another similarity with the findings regarding fearfulness involves the content of worries that are frequently reported by normal children. That is, the majority of studies have revealed self-referent (e.g., threats to oneself rather than to other people) childhood worries (Muris et al., 1998a, 2000; Silverman et al., 1995). Moreover, the content of these worries has been found to change in accord with the child's age. For instance, Vasey et al. (1994) divided children into three age groups (5–6, 8–9, 11–12) and found that self-referent worries were rated the highest among the 5–6 year olds. However, these types of worries decreased significantly as the children's age increased. In the two older groups of children, worries related to behavioural competence, social evaluations, and psychological well being were reported with increased frequency. Furthermore, the older groups of children evidenced a greater array of areas about which they reported worrying.

The findings of Vasey et al. (1994) were essentially replicated in a recent study by Muris et al. (2000) that examined specific worries across children of different ages. This investigation revealed that although separation from parents was rated as the most intense worry for four to six year olds (24.1%), it dramatically decreased with the children's increase in age (5.6%, 0% for 7–9 and 10–12 year olds, respectively). Interestingly, the opposite pattern emerged for test performance which was not reported by any of the youngest children but was indicated as the third highest worry among 7–9 year olds and as the topmost (reported by 46.7%) worry by 10–12 year olds. Thus, childhood worries also appear to be transient and reflective of the child's age and particular life circumstances.

A number of additional findings regarding worry in normal children were revealed in an extensive investigation of 273 second through sixth grade children (Silverman et al., 1995). Children in this study completed self-report measures as well as an interview that sought to determine the nature and features of worry from each of 14 previously identified areas. Health, school, and physical harm were the three most commonly reported worries in this study. In fact, the most frequently reported worry pertained to physical harm or attacks from others and was listed by a striking 56.6% of the children. In ad...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Lists of Figures and Tables
• List of Contributors
• Preface
• Part I. General Issues
• Part II. Anxiety Disorders
• Part III. Epilogue
• Index