Beena Johnson, MBBS, DCH, MD, PhD
Baby Memorial Hospital, Kozhikode,
Kerala, India. PIN: 673004
Address for Correspondence: Dr. Beena Johnson, MBBS,
DCH, MD, PhD. Paediatrician and Senior Consultant in Child
Guidance, Baby Memorial Hospital, Kozhikode, Kerala, India.
Email: jiacam@gmail.com
Abstract
Anxiety disorders are highly prevalent among children and
are associated with serious morbidity. Lifetime prevalence of
paediatric anxiety disorders is about fifteen percent. Social
phobia, generalized anxiety disorder and separation anxiety
disorder are included in the triad of paediatric anxiety
disorders. Specific phobia, obsessive compulsive disorder and
post-traumatic stress disorder are also commonly seen in
children. Overprotection by parents, parental death or
separation, female sex, low educational status, family history
of anxiety disorder, financial stress in family and adverse
childhood experiences are risk factors for the development of
anxiety disorders. If not diagnosed and managed at the
earliest, paediatric anxiety disorders can cause life
threatening problems in the future. Hence early and scientific
management of anxiety disorders is essential. Cognitive
behavioural therapy is the effective evidence based treatment
for paediatric anxiety disorders.
Keywords: Pediatric anxiety disorders, risk factors,
cognitive behavioural therapy.
Introduction
Anxiety is a basic emotion and it is present from infancy. It
is the response of the brain to danger and is an alerting
signal. Symptoms of anxiety in children can range from mild to
severe. The difference between normal and pathological anxiety
should be understood. Normal anxiety is the response to any
threatening situation. For example, separation anxiety usually
occurs at about one year of age and fears of thunder or
lightning occurs at about two years of age. Such anxiety
occurs in many children. But it does not persist and do not
cause much distress. Hence intelligence, language skills and
emotional state of the child must be considered while
diagnosing anxiety disorders in children [1]. Pathological
anxiety is an inappropriate response to a stimulus and is
identified by virtue of its severity and duration. Anxiety
becomes pathological, when it interferes with the normal
functioning of the individual, leading to avoidance of the
anxiety provoking situations and causing significant distress.
Anxiety disorders are the most prevalent emotional disorders
and the onset is during childhood [2]. Anxiety disorders are
more prevalent in girls compared to boys.
Although there is high prevalence of childhood anxiety
disorders, the treatment utilization is very low [3]. If not
diagnosed and managed at the earliest, paediatric anxiety
disorders can lead to significant morbidity during adolescence
and adulthood. It can lead to depression and deliberate
self-harm [4]. Hence, early diagnosis and early intervention
is necessary for paediatric anxiety disorders.
Paediatric Anxiety Disorders
The "paediatric anxiety disorders triad" include social
phobia, separation anxiety disorder and generalized anxiety
disorder. They usually co-occur in children [5]. Common
paediatric anxiety disorders include specific phobias,
separation anxiety disorder, generalized anxiety disorder,
social phobia and obsessive-compulsive disorder [6].
Post-traumatic stress disorder and panic disorder can also
occur in childhood.
Specific Phobia
Children with specific phobia have excessive fear related to a
particular object or situation. This irrational fear
leads to conscious avoidance of the feared object or
situation. The distress in such situations significantly
interferes with the academic functioning and even the normal
daily routines of the child.The usual feared objects and
situations in specific phobia include animals, insects,
blood-injection-injury, illness, darkness, heights, thunder
and lightening.
Social Phobia
These children have excessive and persistent anxiety in one or
more social situations in which they are exposed to unfamiliar
people. They have worry about negative evaluations or scrutiny
by others. They feel very uncomfortable in such social
situations and situationally provoked tantrums or crying can
occur. Children with social phobia will avoid the anxiety
provoking social situations.
Separation Anxiety Disorder
Fear occur for children related to anticipated or actual
separation from the parents or caregivers. These children
usually have school refusal. They have excessive anxiety
and exhibit somatic symptoms upon separation from
parents or caregivers.
Generalized Anxiety Disorder
It is characterized by excessive anxiety and uncontrollable
worry about several events or activities. Generalized anxiety
disorder is associated with symptoms such as, being easily
fatigued, difficulty in concentration, irritability,
restlessness, muscle tension or sleep disturbance. Symptoms
cause marked distress and interfere with social, emotional,
and academic functioning. Common comorbid conditions are
separation anxiety disorder and social phobia.
Obsessive Compulsive Disorder
Children with obsessive compulsive disorder will have
recurring obsessions and compulsions which cause marked
distress and significant impairment in academic functioning
and social activities. Obsessions are recurrent, persistent
and intrusive thoughts, impulses or images which interfere
with the normal routines of the child. Common obsessions in
children include thoughts about contaminations, religious
thoughts, desire for symmetry, doubts regarding completion of
activities and unwanted thoughts related to numbers or
letters. Compulsions are recurring patterns of behaviours or
rituals done by children like handwashing, avoiding, counting
or checking. The child feels driven to perform these
behaviours in response to an obsession.
Post Taumatic Stress Disorder
Children with past exposure to a stressful event of
exceptionally threatening nature, respond with intense fear,
difficulty in concentrating, irritability, sleep disturbance
or disorganised behaviour. They re-experience the traumatic
events through deams or thoughts and experence intense
psychological distress. These children try to avoid the
stimuli associated with the trauma.
Panic disorder
Panic disorder is also seen in children. Recurrent unexpected
panic attacks occur, in which there is sudden onset of various
symptoms like tachycardia, sweating, tremor, chest pain,
nausea, paresthesias, derealization, dizziness, breathing
difficulty, fear of losing control, hot flushes or fear of
dying. Children with panic disorder avoid the situations which
trigger panic attacks.
Prevalence and Onset
All anxiety disorders occur more in females compared to males.
The mean age of onset of anxiety disorders is 11 years [7].
The earliest age of onset is seen for separation anxiety
disorder and specific phobias, especially the animal, blood
injection injury, and environmental types. Onset of social
phobia is usually in late childhood and during adolescence
[8]. Onset of obsessive compulsive disorder can be in early
childhood or adolescence. Generalized anxiety disorder has an
average age of onset of 8 years.
The prevalence of anxiety disorders in children vary from 6 to
20% [9]. Lifetime prevalence of paediatric anxiety disorders
is about 15%. The prevalence of separation anxiety disorder is
about 2.8 to 8% and that of specific and social phobias is
about 10% [10]. Generalized anxiety disorder is prevalent in
about 8% of children. Obsessive compulsive disorder occurs in
about 3% of children. The prevalence of post traumatic stress
disorder is about 2%. Panic disorder has a prevalence of 1% or
lower, during childhood.
Risk factors
Female sex, low educational status and unsatisfactory
financial situations are risk factors for the development of
anxiety disorders. Children of parents with anxiety disorder
have significantly higher risk of developing anxiety disorder.
The risk increases when both parents are affected.
Overprotection by parents can contribute to the development of
phobia, generalised anxiety disorder and panic disorder.
Adverse experiences in early childhood are strong predictors
of anxiety disorders. Parental death and parental separation
are also risk factors for anxiety disorders in children.
Natural Course and Longitudinal Outcome
Anxiety disorders usually have a chronic course. These
disorders wax and wane over time.
In children inter-anxiety comorbidity is common. The severity
of anxiety contributes to the development of depression,
deliberate self harm and substance abuse in the future. If not
managed at the earliest, paediatric anxiety disorders can lead
to significant impairment in academic performance and
personality development of children [9]. This in turn cause
long term impairment in the life of the individual [11].
Role of Cognitive Behavioural Therapy (CBT)
CBT is very effective in reducing the sypmptoms of anxiety
[12-14]. The recommended first line treatment of pediatric
anxiety disorders is CBT [7]. Cognitive-behavioral therapy is
found to be effective in the treatment of anxiety disorders
such as obsessive-compulsive disorder and posttraumatic stress
disorder [15].
CBT for paediatric anxiety disorders has the following
components:
1. Psychoeducation to the child and caregivers
regarding the nature of anxiety.
2. Relaxation techniques for managing somatic symptoms.
3. Cognitive restructuring for the thoughts which provoke
anxiety.
4. Problem-solving skills for coping with the stressors.
5. Systematic exposure to the fearful situations.
6. Desensitization of the feared stimuli and prevention of
relapses.
Several studies have shown the effectiveness of CBT for
pediatric anxiety disorders [9,16-19]. Cognitive behavioral
therapy is effective in treating even preschool children with
anxiety. Randomized control trial has proved the effectiveness
of CBT in four to seven year old children with anxiety
disorders [20].
Conclusion
Paediatric anxiety disorders are common conditions associated
with significant developmental and social complications.
Many children having anxiety disorder will develop depressive
disorders or substance use disorders in future. Paediatric
anxiety disorders are associated with significant functional
impairment and can lead to poor scholastic performance as well
as school refusal. Hence the early vulnerability and risk
factors for anxiety disorders should be identified at the
earliest which is important for the development of preventive
strategies as well as early intervention programs. Early
diagnosis and scientific management of paediatric anxiety
disorders is essential. There is substantial evidence for the
effectiveness of cognitive-behavioral therapy in the
management of paediatric anxiety disorders.
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