Editorial

10.1586/14737175.7.8.909 © 2007 Future Drugs Ltd ISSN 1473-7175 909

Anxiety in children: when is it classed as a disorder that should be treated?‘… a great challenge would be to identify the contribution of each risk factor and ascertain how they may co-occur to produce anxiety.’

Cecilia A EssauSchool of Human & Life Sciences, Roehampton University, Whitelands College, Holybourne Avenue, London, SW15 4JD, UKTel.: +44 208 392 3647Fax: +44 208 392 3527c.essau@roehampton.ac.uk

Expert Rev. Neurotherapeutics 7(8), 909–911 (2007)

Anxiety is a mood state characterized bystrong negative emotion in which the childapprehensively anticipates a threatening eventor situation. Anxiety is a complex pheno-menon that is expressed through three inter-related response systems: physical, cognitiveand behavioral. At the cognitive level, the situ-ation is perceived as either threatening ordangerous. At the physical level, the percep-tion or anticipation of danger involves theactivation of the sympathetic nervous system,which produces both chemical and physicaleffects that help to mobilize the body foraction. At the behavioral level, the urge thataccompanies the fight/flight response is a desireto escape the situa-tion, however, socialfactors may preventthis from happening.This analysis clearlyindicates that theanxiety response can have an adaptive valuewhen a child is actually confronted with dan-gerous stimuli. In fact, moderate levels of anx-iety enhance performance and facilitateimportant developmental transitions.

All children experience anxieties and fearsas a normal part of growing up, although thenumber and type of these anxieties and fearschange with age, which are parallel to thechild’s cognitive and social competencies andconcerns. The fact that all children experi-ence anxiety makes it difficult to differentiatenormal from pathological anxiety (i.e., an

anxiety disorder). As a general orientation, ananxiety is classed as a disorder that should betreated when:

• The duration and intensity does not corre-spond to the real danger of the situation

• It occcurs in a harmless situation

• It is chronic

• It causes impairment and interferes with psy-chological, academic and social functioning

• It occurs in older children who are unable toexplain, reduce and cope with the situation

Our current classification systems – theDiagnostic and Statistical Manual (DSM),currrently in its fourth edition [1], and the

International Classi-fication of Diseases(ICD), currently inits 10th revision [2] –make an explicit dis-tinction between nor-

mal and pathological anxiety based on thenumber, severity, persistence and impairmentof symptoms. Additionally, the symptoms can-not be better accounted for by another of themental disorders, a general medical conditionor as a result of substance use [1]. The develop-ment of standardized diagnostic interviews hasfurther enabled us to reliably evaluate andstudy anxiety disorders.

The most common types of anxiety disordersin children include [1]:• Separation anxiety disorder (i.e., excessive

fears about separation from a caregiver);

‘The fact that all children experience anxiety makes it difficult to differentiate normal from pathological anxiety…’

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Essau

910 Expert Rev. Neurotherapeutics 7(8), (2007)

• Social phobia (i.e., irrational fear of being judged in socialsituations);

• Specific phobia (i.e., fear of specific objects or situations);• Generalized anxiety disorder (i.e., excessive and uncontrollable

worry about life events);• Obsessive–compulsive disorder (i.e., intrusive illogical

thoughts and repetitive behaviors);• Panic disorder (i.e., discrete fear attacks that are associated

with cognitive and physical symptoms);• Agoraphobia (i.e., fear of being in places that are difficult to

escape from);• Post-traumatic stress disorder (i.e., a reaction to a severe

trauma that is characterized by re-experiencing of the event,hyperarousal and avoidance symptoms).The common characteristics of all these anxiety disorders are

excessive or inappropriate anxiety that causes significantimpairment in functioning; they differ in regard to the natureof the feared stimulus and the anxiety response produced by it.

According to recent epidemiological studies, approximately10–20% of children met the lifetime criteria for an anxiety dis-order [3,4]. These data indicate that anxiety disorders are themost common psychiatric disordersaffecting children. Anxiety disordersoccur across all age and ethnicgroups, and in all socioeconomic sta-tuses. Childhood anxiety disorderscan result in school refusal, somaticcomplaints, social withdrawal andlow self-esteem. Anxiety disorders also co-occur highly withother psychiatric disorders [5], which complicates the clinicalmanagement in at least three respects [6]. First, symptom over-lap between disorders and symptom overshadowing by behav-ioral disorders could confound the diagnostic assessment ofanxiety. Second, differentiating impairment caused by anxietyfrom impairment due to other psychiatric disorders is difficultto ascertain. Finally, in terms of treatment, it needs to bedecided which disorder takes precedence and how treatment ofcomorbid disorders may affect the anxiety disorder.

Challenges & unresolved issuesAlthough major advances have been achieved in childhoodanxiety research within the last decade, there are numerousunresolved issues and challenges that need to be dealt with.

Most studies of anxiety disorders in children have used theadult criteria for anxiety based on the DSM or the ICD,although little is known about the validity or the reliability ofthese criteria when applied to children. Furthermore, ourclassification systems are not sensitive enough to develop-mental issues and little attempt has been made to specify theage at which specific diagnoses become valid. This makes itdifficult to decide whether symptoms occur frequentlyenough to be clinically significant because certain problem-atic behaviors may be developmentally appropriate. There-fore, the diagnosis of anxiety disorders in childhood should

be sensitive to the child’s developmental stage as well as toconstitutional and environmental factors that affect theirdevelopmental progress.

Children at different ages may differ in their ability to reporttheir emotions, feelings and behaviors. To evaluate similar char-acteristics across the age groups may require different measures,and include some changes of the same measures. However, anychanges of assessment procedures may influence the results andconsequently the conclusions since the same items may beinterpreted differently by children at different developmentalstages. Furthermore, in assessing age-appropriateness versusclinical relevance of children’s behavior, there is a need to knowthe age appropriateness of the behavior. A challenge is todefine age-appropriate behaviors, and find a way to operation-alize them. In this respect, milestones of normal developmentmay be useful. At the same time, the heterogeneity of child’sdevelopment needs to be taken into account.

In order to have a comprehensive and accurate picture ofthe children’s anxiety, data needs to be gathered from multiplesources. Unfortunately, agreement among informants on thefrequency and severity of anxiety disorders has been low [7].Given the lack of agreement among different informants, the

important decision that mustbe reached is which informa-tion from which informantsshould be used. In clinicalsettings, it is usually the clini-cians who weigh the informa-tion obtained from the differ-

ent informants and make a decision about diagnosis andtreatment. However, the way in which clinicians weigh dis-crepant information is unclear. Additionally, there are practi-cal considerations and difficulties for clinicians, includingtime constraints.

Despite the high comorbidity both within the anxiety dis-orders as well as between anxiety and other disorders, themeaning of comorbidity for etiological and classification issuesremains unresolved. It is not clearly known if the highcomorbidity of anxiety disorders may reflect the overlappingdiagnostic criteria or artificial subdivision of syndromes in ourcurrent classification systems, or if comorbidity could havebeen the consequence of the same risk factors. It could also bethat one disorder may represent an early manifestation ofanother disorder, or that one disorder causes or lowers thethreshold for the expression of the other. Certainly, issues relatedto the temporal sequences of disorders may shed light into this.

Some of the most consistent factors implicated in the develop-ment and maintenance of anxiety disorders include: cognitivedysfunction, life events and family and genetic factors [5,6].However, one needs to be cautious in interpreting and generaliz-ing the existing results because risk factors tend to aggregate overtime and contribute to anxiety, and the same factors do not nec-essarily lead to anxiety in most people. Therefore, a great chal-lenge would be to identify the contribution of each risk factorand ascertain how they may co-occur to produce anxiety.

‘Although major advances have been achieved in childhood anxiety research

within the last decade, there are numerous unresolved issues and challenges that

need to be dealt with.’

Anxiety in children

www.future-drugs.com 911

In terms of treatment, the two main categories of pharmaco-logical agents often used to treat anxiety disorders in older chil-dren are antidepressants and anxiolytics. However, most studiesthat examined the efficacy of these medications are problematicowing to methodological limitations, including small samplesizes, and lack of double-blind and placebo-controlled studies.Psychological interventions commonly used to treat anxiety dis-orders include cognitive–behavioral therapy (CBT). Despite theeffectiveness of CBT in treating anxiety disorders, a major chal-lenge is reaching those who need the help the most. A large pro-portion of anxious children in the community do not receive theprofessional help they need [8]; most of those who sought treat-ment were treated in general medical or primary-care settingsand their anxiety was often undetected and misdiagnosed.

To conclude, although progress have been made in anxietyresearch in children, there are several issues which need to beresolved, including:

• The validity and reliability of using adult criteria for anxietydisorders among children

• The problem of a lack of agreement in the information fromdifferent informants

• The effects of comorbidity between anxiety and otherpsychiatric disorders on classification and etiology

• The nonspecificity of risk factors for anxiety

• The low rates of mental health services utilization

It is hoped that this editorial will stimulate future researchinto anxiety among children.

ReferencesPapers of special note have been highlighted as:• of interest•• of considerable interest

1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th Edition). American Psychiatric Association, Washington, DC, USA (1994).

2 World Health Organization. International Classification of Mental and Behavioral Disorders. World Health Organization, Geneva, Switzerland (1993).

3 Essau CA, Conradt J, Petermann F. Frequency, comorbidity, and psychosocial impairment of anxiety disorders in adolescents. J. Anxiety Disord. 14, 263–279 (2000).

4 Lewinsohn PM, Rohde P, Seeley JR. Treatment of adolescent depression: frequency of services and impact on functioning in young adulthood. Depress. Anxiety 7, 47–52 (1998).

5 Essau CA. Comorbidity of anxiety disorders in adolescents. Depress. Anxiety 18, 1–6 (2003).

6 Vasa R, Pine D. Anxiety disorders. In: Child and Adolescent Psychopathology: Theoretical and Clinical Implications. Essau CA (Ed.). Brunner-Routledge, London, UK 78–112 (2006).

• Provides a comprehensive review of recent studies on childhood anxiety.

7 Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychol. Bull. 101, 213–232 (1987).

8 Essau CA. Use of mental health services among adolescents with anxiety and depressive disorders. Depress. Anxiety 22, 130–137 (2005).

• Established mental health services utilization rates among children and adolescents with anxiety and other disorders.

Affiliation

• Cecilia A Essau, PhD, MA

Professor of Developmental Psychopathology, School of Human & Life Sciences, Roehampton University, Whitelands College, Holybourne Avenue, London, SW15 4JD, UKTel.: +44 208 392 3647Fax: +44 208 392 3527c.essau@roehampton.ac.uk