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BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183
Anxiety disorders in children and ARTICLE
adolescents: aetiology, diagnosis
and treatment †
Aaron K. Vallance & Victoria Fernandez
In ICD-10, anxiety disorders are classified into Aaron K. Vallance is a consultant
SUMMARY in child and adolescent psychiatry in
a cluster of related conditions: separation anxiety,
The presentation of anxiety disorders in children and Surrey CAMHS (Surrey and Borders
generalised anxiety, social phobia, panic disorder Partnership NHS Foundation Trust)
adolescents shares similarities and differences with
and simple phobias (World Health Organization and an honorary clinical senior
that in adults, and may vary significantly, depending lecturer in the Faculty of Medicine
1992). Although beyond the remit of this chapter,
on the age of the individual. Assessment must (Faculty of Education), Imperial
differentiate anxiety disorders from developmentally anxiety can feature in other psychiatric conditions.
College London. He has an MA
appropriate fears as well as medical conditions In obsessive–compulsive disorder (OCD), obsessions (Oxon) in Psychology, Philosophy
and drugs that can mimic anxiety states. Aetiology generate anxiety which the individual then and Physiology and a Masters in
of anxiety disorders in this group encompasses tries to neutralise through compulsions. Indeed, Education. His specialist interests
include medical education, and he
complex genetic and environmental influences. DSM-5 defines and differentiates obsessions and has written on various aspects of
Additional insight into causation is provided by compulsions through their causal relationships child and adolescent psychiatry.
neuroimaging and research into temperament. with anxiety (American Psychiatric Association Victoria Fernandez is a consultant
Recommended interventions include both 2013). This may be a simplification: although in child and adolescent psychiatry
cognitive–behavioural therapy and pharmacology. with Deaf CAMHS, South West
compulsions may initially relieve anxiety, they can London and St George’s Mental
Although childhood anxiety disorders generally
aggravate it as the disorder progresses (Heyman Health NHS Trust (SWLSTG).
remit, there remains an increased risk for anxiety
and depressive disorders to emerge in adulthood, 2006). Swedo et al (1998) describe separation She has a special interest in
undergraduate and postgraduate
most likely through heterotypical continuity. anxiety as a characteristic feature of the proposed
medical education, with roles as
‘paediatric autoimmune neuropsychiatric disorders an honorary teaching fellow for
LEARNING OBJECTIVES associated with streptococcal infections’ (PANDAS) Imperial College London, Training
• Understand the nature of anxiety disorders in subset of OCD, although recent research disputes Programme Director for higher
children and adolescents, including their range, this (Murphy 2012). Anxiety also occurs in post- training in child and adolescent
epidemiology and presentation psychiatry for SWLSTG, and
traumatic stress disorder (PTSD), particularly Undergraduate Lead for psychiatry
• Comprehend the complex aetiological influences
when traumatic memories are triggered. Avoidance local and international placements
(e.g. genetics, family environment, brain develop- at St George’s, University of London.
behaviour and hypervigilance are common and can
ment) on the pathogenesis of these disorders Correspondence Dr Aaron K.
be seen as an adaptive response to avoid further Vallance, West Surrey CAMHS
• Appreciate the assessment process for anxiety
dangers, albeit one that is excessive, distressing Community Team, Azalea House,
disorders in this group and the variety of
and/or impairing. Anxiety in PTSD may relate to Farnham Road Hospital, Guildford
treatment options, encompassing psychological GU2 7LX, UK. Email: aaron.
therapies and psychoactive medications dysfunction of the hypothalamic–pituitary–adrenal
vallance@sabp.nhs.uk
(HPA) axis.
DECLARATION OF INTEREST From an evolutionary perspective, anxiety is an
None emotional response intrinsically shaped by natural †This is an updated version of a
selection: its very purpose is to ensure safety, avoid chapter published in Huline-Dickens
S (ed) (2014) Clinical Topics in Child
Anxiety is an uncomfortable experience charac danger and keep the individual alive (at least long and Adolescent Psychiatry. RCPsych
terised by emotional (e.g. unease, distress), cognitive enough to pass on their genes). Anxiety is therefore Publications.
(e.g. fears, worries, helplessness), physiological (e.g. a normal and important facet of human experience
muscle tension) and behavioural (e.g. avoidance) and functioning.
changes. The anxious child commonly focuses The various subtypes of anxiety disorder
on the future, fearful of danger, either specific or probably evolved to give a selective advantage
undefined. Anxiety that is excessive or contextually of superior protection against particular kinds
or developmentally inappropriate, causing signi of danger (Marks 1994). Yet commonalities exist
ficant distress and/or functional impairment, can between these subtypes, for example in their
be classified as an anxiety disorder. Although shared behavioural responses (Table 1). Again,
rarely recognised, too little anxiety might also be this may be evolutionarily driven, reflecting a
considered ‘disordered’: callous unemotional traits need for flexibility in dealing with uncertain or
may be such a manifestation (Frick 1999). indefinable threats. Furthermore, physiological and
335Vallance & Fernandez
TABLE 1 Evolutionary protective roles associated with anxiety-related behaviours Epidemiology
Anxiety disorders are some of the most prevalent
Behaviour Protective role
psychiatric disorders in children and adolescents,
Escape or avoidance Distances an individual from certain threats particularly among girls (Table 3). They also
Aggressive defence Harms the source of danger frequently co-occur: at least one-third of children
Freezing/immobility Helps to locate and assess the danger presenting with an anxiety disorder meet the
Concealment criteria for two or more subtypes. Moreover, general
Inhibits the predator’s attack reflex comorbidity with other psychiatric disorders
Submission/appeasement Protects the individual when the threat comes from their own group – including oppositional defiant disorder and
Submission to group leaders and to group norms prevents
dangerous expulsion from the group
attention-deficit hyperactivity disorder (ADHD),
Mild shyness may promote acceptance substance misuse and depression – is approximately
Separation anxiety can help promote the attachment of the child 40%; comorbidity with depressive disorder is about
to the mother
28%. Anxiety disorders are frequently found in
After Marks & Nesse (1994). autism spectrum disorders, with rates as high as
84% (Muris 1998).
behavioural responses useful against one type of
danger are likely to protect against other types as
well. Indeed, our hunter-gatherer ancestors would Clinical features of anxiety disorders
have faced multiple threats: predators, starvation, The ICD-10 diagnostic criteria for all types of
climate, falls and exposure. anxiety disorder stipulate the presence of both
The shifting manifestation of anxiety through emotional and physiological symptoms, either in a
different developmental stages may also have an specific feared situation or for a specific duration.
evolutionary basis (Table 2). Fears tend to occur at
the age they become adaptive: for example, fear of Separation anxiety disorder
animals occurs from 2 to 3 years old, when there is Separation anxiety disorder is an excessive and/
increased exploration, and this may have a protective or developmentally inappropriate anxiety about
value. In adolescents, developing cognitive maturity separation from attachment figures. Excessive
endows individuals with a growing capacity to worrying about the figure’s welfare may also occur.
imagine and ruminate on abstract threats. The Impairment might include school refusal (possibly
developmental aspect of anxiety is an important exacerbated by specific school anxiety), avoidance
consideration: what is seen as normal for a young of visiting friends’ homes or difficulty sleeping
child may be considered a disorder in an older child. alone. The ICD-10 criteria include onset before 6
So, for example, screaming when separated from years of age and duration of at least 4 weeks.
a mother may be quite normative in a preschool
child, but in an 11-year-old it would be unusual. Generalised anxiety disorder
Generalised anxiety disorder encompasses multiple
TABLE 2 Fear and its typical developmental stages and persistent worries (e.g. regarding family,
friendships, school or appearance) not restricted to
Age Typical fears any one situation or object, lasting at least 6 months.
9 months to 3 years Sudden movements or loud noises, separation from caregivers, strangers Comorbidity (e.g. with depression) is particularly
common. In ICD-10, diagnostic criteria for children
3–6 years Animals, the dark, ‘monsters/ghosts’
and adolescents are differentiated from those for
6–12 years Performance anxiety
adults. The former include an additional ‘difficult-
12–18 years Social anxiety, fear of failure/rejection to-control worries’ criterion, and requires three or
Adulthood Illness, death more physical symptoms from six, a condensed list
to reflect the reduced prominence of autonomic
Epidemiological characteristics of anxiety disorders in children and arousal in children.
TABLE 3
adolescents It is not clear yet what modifications will be
made in the revised version, ICD-11, although
Disorder Prevalence, % Typical age at onset Shear (2012) proposes various changes for the
Separation anxiety disorder 2–4 Prepuberty; peaks at 7 years adult criteria, including a requirement that worry
must occur frequently and/or excessively, focusing
Generalised anxiety disorder 3 Increased incidence in adolescence
the somatic criteria on restlessness and muscle
Panic disorder 5 Late teens
tension, and permitting the diagnosis even in the
Social phobia 1–7 11–15 years presence of other anxiety disorders. Interestingly,
Specific phobia 2–4 >5 years these criteria are already present in the ICD-10
Source: Vallance & Garralda (2011). children’s diagnosis.
336 BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183Anxiety disorders in children and adolescents
Social phobia and social anxiety disorder an often overlapping cluster of phobias relating
of childhood to at least two of crowds, public places, leaving
Social phobia is accompanied by an excessive home and travelling alone. Various specific worries
fear of embarrassment or scrutiny. Avoidance may reinforce the anxiety, including fears of
of particular social situations reinforces the collapsing, being left helpless in public and being
associated anxiety and could eventually impede unable to escape. Persistent avoidance may result
social skills development and, at the most extreme, in the experience of minimal anxiety, so that the
result in debilitating social isolation. In DSM-5, agoraphobia escalates until the individual becomes
‘social phobia’ is a single category, but in ICD-10 housebound.
it is differentiated from ‘social anxiety disorder
of childhood’ (American Psychiatric Association
Panic disorder
2013). Social anxiety disorder of childhood occurs Panic disorder involves repeated and unexpected
at a developmental stage at which social anxiety attacks of severe anxiety not restricted to any
reactions are appropriate – diagnostically, it must particular situation, accompanied by multiple
manifest before 6 years of age – but in an affected physical symptoms. It often originates from the
child they involve significant severity, persistence or occasional panic attack in adolescence, although
impairment lasting for at least 4 weeks. In contrast, only a small proportion of young people who have
social phobia reflects social anxiety later in life, such attacks subsequently develop the disorder.
and includes blushing, shaking, or fear of vomiting, Anticipatory anxiety about future attacks or their
micturition or defecation; no minimum duration of perceived implications (e.g. losing control, being
symptoms is given. judged) is common. In keeping with ICD-10,
Emmelkamp (2012) argues that ICD-11 should DSM-5 has now separated agoraphobia and panic
also include a minimum symptom duration for disorder into distinct entities, particularly as many
social phobia, following the new inclusion of a individuals with agoraphobia do not experience
minimum 6 months’ duration in DSM-5. Wittchen panic symptoms.
et al (1999) distinguish between generalised
social phobia (across multiple settings) and non- Assessment
generalised: the former is associated with greater Children and young people with anxiety disorders
chronicity, impairment and comorbidity. Autism may not present to services overtly complaining of
spectrum disorder is a differential (particularly anxiety. They may also have difficulty articulating
where social isolation is a function of impaired their experiences or be confused or embarrassed
social communication and/or lack of social interest by them. Nevertheless, making an early diagnosis
rather than frank anxiety) or commonly comorbid is important, as many anxiety disorders remain
diagnosis. untreated in the community, causing distress and
impeding academic and social functioning.
Specific or simple phobias Assessment should differentiate between develop
Specific or simple phobias are defined by excessive mentally appropriate fears and anxiety disorders. It
fear of specific objects or situations that provoke an should also consider potential aetiological factors
immediate anxiety response on exposure, causing and developmental influences. Differential and
significant distress and/or functional impair comorbid diagnoses include autism spectrum
ment, for example because of avoidance. Fyer disorder, oppositional defiant disorder, ADHD,
(1998) describes subtypes relating to: animals, depression and PTSD. Differentiating between
specific situations, nature/environment (e.g. water, diagnoses can be challenging given the overlapping
heights) and blood injury. Not only do they differ symptoms. For example, fatigue, irritability, and
in their triggers, they may also vary with respect sleep and concentration problems can occur in both
to symptomatology, age at onset and heritability. generalised anxiety and depression.
Blood injury phobia, for example, has a distinct History-taking should aim to exclude medical
biphasic physiological response. Some typical fears disorders and drugs that can mimic or provoke
held by children and adolescents are described anxiety states (Table 4). If an organic disorder
in Table 2. The DSM-5 criteria no longer require suggests itself, it can be followed up through physical
the individual to recognise that their anxiety is examination and targeted investigations (BMJ
excessive or unreasonable: instead, the onus is Evidence Centre 2016). Liaison with general prac
on the clinician to determine whether anxiety is titioners and/or paediatricians may be indicated.
disproportionate to the situation. Validated self-report scales, such as the Multi
This particular DSM-5 criterion of due proportion dimensional Anxiety Scale for Children (MASC;
also relates to agoraphobia, which encompasses March 1997) and the Screen for Child Anxiety
BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183 337Vallance & Fernandez
TABLE 4 Medical conditions and drugs that can mimic anxiety symptoms, with potential childhood is a risk factor for anxiety, particularly
further investigations social phobia, later in childhood and adolescence
(Perez-Edgar 2005). Similar associations have
Possible further
Notes investigations been reported for shyness and an anxious-resistant
attachment style. The 21-year longitudinal study
Medical conditions
by Goodwin et al (2004) showed that anxious/
Hyperthyroidism Characteristic symptoms include goitre, Thyroid function tests withdrawn behaviour at 8 years of age increased
weight loss, warm moist skin, heat
intolerance and ophthalmopathy the risk of anxiety disorders and depression in
The most common cause is the autoimmune adolescence and young adulthood.
Grave’s disease, which is not uncommon in However, the relationship is complex, it varies
adolescents
according to the study (Degnan 2010) and much
Arrhythmias Sinus tachycardia is a normal increase in Electrocardiogram and
heart rate (e.g. exercise, excitement) echocardiogram of the association may lie at the extremes of
The most common childhood abnormal temperament (Kagan 2002). Furthermore, other
tachycardia is supraventricular moderating factors (e.g. peer rejection, exclusion
Epilepsy ‘Ictal fear’ can accompany focal seizures Electroencephalogram and victimisation) play a significant role as the
Anxiety symptoms may occur as a seizure
prodromal symptom child develops.
Pheochromocytoma Characteristic symptoms include 24-hour urine test for
tachycardia and hypertension vanillylmandelic acid Genetics
Mostly presents in young adulthood, but and metadrenaline Family studies indicate an association between
can occur earlier if hereditary
parental anxiety and depression and anxiety
Asthma Characteristic symptoms include wheezing, Pulmonary function
cough, chest-tightness tests disorders in offspring. The association appears
Asthma is common in childhood, and is to be largely non-specific (in terms of anxiety
associated with an increased risk of panic subcategory), except for a particular relationship
disorder (where it is also a differential
diagnosis) and separation anxiety between parental panic disorder and offspring
separation anxiety disorder (Biederman 2004).
Drugs
Twin studies in adults suggest that generational
Street drugs For example, amphetamines, cocaine Urine drug screen
transmission is primarily accounted for by non-
Sympathomimetics For example, pseudoephedrine for nasal
congestion shared environmental and genetic factors, with a
Caffeine From tea, coffee, caffeinated drinks heritability of about 40% for panic, generalised
and agoraphobic anxiety, and specific phobias
(Hettema 2001). Such studies in children show
Related Disorders (SCARED; Birmaher 1997), more variation. For example, Bolton et al (2006)
have shown correlation with anxiety severity and reported a heritability of 60% for specific phobias
treatment effects. Clinician scales include the and 73% for separation anxiety disorder, whereas
Pediatric Anxiety Rating Scale (PARS; Research Eley et al (2008) found the figures to be 46% and
Unit on Pediatric Psychopharmacology Anxiety 14% respectively. Both studies show significant
Study Group 2003). Assessment should also focus influence of non-shared environmental factors.
on the distress and impairment to the individual However, the latter study also shows a significant
and their family. This would include suicidality, shared environmental contribution for specific
which is increased in anxiety disorders. Adolescents phobia (at 0.27, as for non-shared factors), which
may also resort to alcohol and other substances as suggests that familial factors (such as parental
ways of coping. overprotection or control) may be as influential
as non-shared factors (e.g. conditioning) for this
Aetiology disorder.
Despite their symptomatic variation, anxiety Furthermore, research indicates both common
disorders may share some common aetiological or and distinct genetic aetiologies across some types
pathophysiological characteristics. of anxiety and affective disorder. For example,
generalised anxiety and major depressive disorders
Temperament appear to share a common genetic aetiology,
Research suggests a relationship between pre- but diverge in their non-shared environmental
existing personality traits and later anxiety factors. Twin studies in adults indicate a similar
disorders. One such trait is inhibited temperament, genetic substrate underlying panic disorder and
or behavioural inhibition, defined by Kagan and generalised anxiety disorder, but a distinct one for
colleagues as a tendency to show apprehension specific phobias (Hettema 2005). Another twin
to novel or unfamiliar situations, together with study showed a shared genetic diathesis between
raised reactivity of the sympathetic nervous system adult-onset panic attacks and earlier separation
(Kagan 1999). Such behavioural inhibition in early anxiety disorder, but not for what was previously
338 BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183Anxiety disorders in children and adolescents
called childhood overanxious disorder (Roberson- ‘fear circuit’ encompassing the amygdala, ventral
Nay 2012). The paediatric anxiety twin study by prefrontal cortex and the anterior cingulate cortex
Eley et al (2008), however, showed no significant (McClure 2007).
genetic covariation between specific phobias, Pine (2007) has attempted to unify neuroimaging
separation anxiety and social phobia, implying research (e.g. amygdala–prefrontal circuitry abnor
distinct biological substrates for each. malities) with affective and cognitive research (e.g.
Twin studies therefore indicate that genetic memory, learning, emotional regulation and fear
factors endow a broad susceptibility to anxiety in conditioning) in a single neuropsychological model.
general as opposed to a specific disorder. This again This describes various information-processing
may reflect an evolutionary ‘balancing act’ between biases in anxiety disorder: for example, the
specialisation (to deal potently with specific threats) tendency to direct attention towards environmental
and generalisation (necessary for protection against threats, and appraise such threats as particularly
several types of danger arising from the evolutionary meaningful and dangerous. The development of
coexistence of multiple threats). There is probably neural substrates underlying the fear response
a stronger relationship between genetic factors and and anxiety is likely to involve complex gene–
various neuropsychological processes (including environment interplay, including the influence of
behavioural inhibition) or traits (e.g. neuroticism), early life experiences (Fox 2005).
rather than specific psychiatric disorders.
Finally, adult molecular genetic studies suggest Parent–child interactions and the family
serotonin transporter dysfunction, although environment
paediatric studies are few. Fox et al (2005) explored Retrospective and observational studies have
gene–environment interaction and showed that found that parental overcontrol, rejection and
children with a combination of the short 5-HTT modelling of anxious behaviours are consistently
allele and low social support had increased risk for and significantly associated with childhood shyness
behavioural inhibition. and paediatric anxiety disorders (Degnan 2010).
Specifically, aspects of parenting behaviour (e.g.
Neuroimaging and neuropsychology oversolicitous, intrusive or controlling parenting),
The few neuroimaging studies conducted with style (e.g. authoritarian, permissive, low-proactive
children have shown some interesting structural and low-supportive parenting as perceived by
findings. Replicating results in adults, Koolschijn children, or overprotective parenting as reported by
et al (2013) found an association between reduced parents), psychopathology (e.g. parents diagnosed
left hippocampal volume and higher scores for with panic disorder and/or depression), personality
anxiety and depression on the Child Behavior (e.g. maternal neuroticism) and the parent–child
Checklist. Milham et al (2005) found reduced left relationship (e.g. insecure attachment) have been
amygdala grey matter volume associated with linked to heightened behavioural inhibition and/or
anxiety disorders. Intriguingly, a pilot follow-up anxiety in children. Parenting factors are therefore
study showed recoveries in amygdala grey matter likely moderators of the relationship between
volume after successful 8-week intervention with behavioural inhibition and the development of
selective serotonin reuptake inhibitors (SSRIs) childhood anxiety. However, the degree to which
or psychotherapy. the child’s anxiety has a reverse influence on
Various studies have explored relationships parenting is unclear. These parenting styles are also
between early temperament and neuroanatomy implicated in other child psychiatric disorders.
or neurophysiology. Schwartz et al (2003) used Such parenting may hinder the development of
functional magnetic resonance imaging (MRI) autonomy, resulting in a child who experiences the
to show that adults who had had an inhibited environment as more threatening and less safe. Lack
(compared with uninhibited) temperament at of parental emotional availability, for example as a
2 years old showed greater amygdala signal response result of social adversities such as overcrowding,
to novel faces. Schwartz et al (2010) subsequently poverty and marital discord, may impede parents’
used structural MRI to show that adults who ability to help contain their children’s anxieties;
had had a low-reactive temperament in infancy children living in families where there are such
showed greater left orbitofrontal cortex thickness, chronic stressors are more likely to experience
whereas those who had had high reactivity showed insecurity and to feel anxious and fearful. Also,
greater right ventromedial prefrontal cortex parents who themselves have increased trait
thickness. Functional MRI research in young anxiety and sense of threat may exacerbate the
people with generalised anxiety disorder has perception of threat in these children and obstruct
shown that variations in state anxiety modulate the development of coping skills; modelling may
associations between attention and activation in a therefore be a significant contributing factor.
BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183 339Vallance & Fernandez
Parent–child interaction also, of course, occurs in CBT and psychological therapy
utero, and research shows that maternal stress or
As already mentioned, the NICE guideline recom
anxiety in pregnancy can influence psychopathology
mends CBT for anxiety disorders. It incorporates
in the offspring (Glover 2011). Bergman et al
both cognitive (e.g. reframing, positive self-talk,
(2007) showed that prenatal stress predicts
challenging unhelpful thoughts, and weighing up
observed fearfulness in the offspring. Van den
evidence for and against expected events) and
Bergh & Marcoen (2004) used multiple regression
behavioural processes (e.g. systematic desensi
analysis to show that maternal state anxiety in the
tisation, exposure and response prevention for
second (but not the third) trimester correlates with
specific phobias, relaxation training, modelling and
anxiety in 8- and 9-year-olds. O’Connor et al (2002)
rewarding wanted behaviour, and role-play).
showed that antenatal anxiety (but not depression)
Depending on the anxiety disorder and the child’s
in late pregnancy is independently associated with
age, either cognitive or behavioural strategies can
behavioural/emotional problems in 4-year-olds.
be emphasised. Various manuals (e.g. Stallard
Prenatal stress may also lead to neuroanatomical
2002) provide accessible material for both clinician
changes in offspring, such as reduced hippocampal
and patient. Family and school can support the
and grey matter volume (Glover 2011), consistent
child and help with graded exposure tasks and
with neuroimaging data discussed above. From an
experiments such as those described by Kendall
evolutionary perspective, the effects of prenatal
et al (2005).
stress on fetal neurodevelopment may allow
Two relatively recent meta-analyses of psycho
offspring to readily adapt to the same potentially
logical therapies for anxiety disorders in children
stress-inducing environment as experienced by the
and young people (Ishikawa 2007; Reynolds 2012)
mother. Glover (2011) also suggests that outcomes
also included a few trials relating to PTSD and
become non-adaptive if the manifesting anxiety is
OCD (Table 5). Both meta-analyses showed signifi
excessively extreme for the respective environment.
cant effect sizes for CBT, which remained significant
but attenuated when analysis was limited to stud
Traumatic life events
ies with an active control methodology (as opposed
Traumatic events predispose not only to PTSD, to waiting-list or treatment-as-usual groups). Both
but also to various anxiety disorders, particularly reported that involving parents had a positive but,
specific phobia and social phobia (McLaughlin perhaps surprisingly, relatively minor effect.
2012). Pine et al ’s (2002) longitudinal study These two meta-analyses also yielded some
found that adverse life events in adolescence were divergent data, possibly because of their differing
associated with symptoms of generalised anxiety inclusion criteria, number of studies included, date
disorder in adulthood, but only in females. of publication and outcome measures. While the
Ishikawa team found little difference in effect size
Respiratory dysregulation
between delivering fewer versus many sessions,
Recurrent dyspnoea, particularly in asthma, is a risk the Reynolds team showed that having less than
factor for paediatric anxiety disorders such as panic 9 hours of therapy reduced the effect size and
and separation anxiety (Goodwin 2003). Sensitivity less than 4 hours had minimal therapeutic effect.
to carbon dioxide, a respiratory stimulant, has also And whereas the Ishikawa team demonstrated
been found in children with anxiety disorders, little difference in effect size between group and
particularly separation anxiety (Pine 2005). individual CBT, the Reynolds team showed a
particularly high effect size for individual CBT.
Interventions However, delivering CBT to a group may arguably
The National Institute for Health and Care enhance efficiency and provide peer support and
Excellence (NICE) guideline on generalised anxiety reassurance. An open trial has recently shown
and panic disorders in adults covers principles that evidence supporting a novel CBT package (Emotion
can be extrapolated to children and adolescents Detectives Treatment Protocol) delivered to a group
(NICE 2011). For example, early psychoeducation of children with various anxiety and depressive
can help families understand the condition and disorders (Bilek 2012).
provide reassurance, and self-help may encompass Computerised CBT packages such as
written and electronic materials. Interventions Stressbusters (Abeles 2009) have now been
with a significant evidence base include cognitive– developed for childhood anxiety disorders. Their
behavioural therapy (CBT) and SSRI medication. advantages and disadvantages are listed in Box
It is important to ascertain the expectations and 1 (Richardson 2010). Two randomised controlled
preferences of the young people and their families and trials (RCTs), each with over 70 participants,
to make treatments developmentally appropriate. showed significant differences between CBT (using
340 BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183Anxiety disorders in children and adolescents
the BRAVE-ONLINE package) and control groups. TABLE 5 A comparison of two meta-analyses of the efficacy of psychological therapies
Furthermore, remission rates in the treatment for anxiety disorders
groups were approximately 75% at 6 months
Mean effect size
(March 2009) and at 12 months (Spence 2006).
Spence et al ’s study also included a clinic-based CBT Ishikawa et al (2007) Reynolds et al (2012)
arm; overall results showed no significant difference Factor 20 studies 55 studies (48 on CBT)
between internet- and clinic-delivered CBT. CBT (overall v. control) n.a. 0.66*
The evidence base for other forms of psychological
CBT (pre- v. post-) 0.94* n.a.
therapy is less robust. Family therapy may help
CBT v. passive control 0.68* 0.77*
where dysfunctional patterns of family interaction
influence the child’s anxiety symptoms. Parents CBT v. active control 0.61* 0.39*
may also need support for their own difficulties Individual CBT 0.66* 0.85*
with anxiety and/or separation to prevent them Group CBT 0.59* 0.58*
from exacerbating their child’s symptoms. Fewer sessionsVallance & Fernandez
compared with those treated with psychological community epidemiological study by Bittner et al
therapy alone (Hopkins 2015). (2007) showed that various anxiety disorders in
Although the situation regarding the relationship childhood predicted anxiety and other psychiatric
between suicidality and antidepressants in anxiety disorders in adolescence; the only exception was that
disorders is less clear, the Cochrane review of generalised anxiety disorder specifically predicted
antidepressant use in paediatric anxiety disorders only conduct disorder. In contrast, the longitudinal
(Ipser 2009) indicated an absolute rate of suicidal study by Pine et al (1998) showed that adolescent
ideation of approximately 1%, primarily those social phobia predicted primarily social phobia
taking paroxetine or venlafaxine. In the UK, in adulthood, whereas simple phobias predicted
no antidepressants are currently licensed for primarily simple phobias. They also found broad
paediatric anxiety disorders, although sertraline associations between generalised anxiety, panic
and fluvoxamine are licensed for paediatric OCD. and major depressive disorders, with a particularly
There is little evidence to support the use of strong association between adolescent depression
non-antidepressant medication. Studies have failed and adult generalised anxiety disorder. The 7-year
to show significant efficacy of benzodiazepines, longitudinal study by Aschenbrand et al (2003)
and their side-effects, for example behavioural explored whether childhood separation anxiety
disinhibition, are a risk. Such side-effects can also specifically constitutes a precursor for later panic
occur for buspirone, although case reports and open disorder and agoraphobia, but found no evidence
studies have shown some efficacy. There have been of this. Overall, adolescent anxiety or depression
few studies of beta blockers. Further information predicts an approximate two- to threefold increase
on pharmacotherapy in paediatric anxiety disorder in risk for adult anxiety disorders (and for suicide
can be found in Sinita & Coghill (2014). attempts, psychiatric admissions, and alcohol and
substance misuse).
Prognosis Weems (2008) argues for heterotypical continuity
Studies evaluating longitudinal outcomes indicate in anxiety disorder: although an individual’s
that childhood anxiety disorders generally remit. anxiety disorder may remit and return, often as
For example, the prospective study by Last et al a different disorder type, underneath lies a core
(1996) on children with a mean age of 12 years maladaptive anxiety emotion that exhibits a larger
found that recovery rates over 3–4 years were 96% degree of continuity. Various aetiological factors
for separation anxiety disorder, 86% for social (e.g. genetic, temperamental, neuropsychological,
anxiety disorder, 80% for overanxious disorder, and interpersonal and environmental) may influence
about 70% for specific phobia and panic disorder. the emergence and course of anxiety disorders;
The prognosis for anxiety disorders depends on type normative developmental changes may also
of disorder, comorbidity, age at onset and severity at affect their trajectory and expression into specific
baseline. The 2-year longitudinal study by Broeren disorders.
et al (2013), exploring developmental trajectories
for various types of childhood anxiety symptoms, Conclusions
also showed that high levels of initial behavioural Paediatric anxiety disorders are relatively common
inhibition correlated with 2-year trajectories of and often disabling. They increase the risk of
higher anxiety. psychopathology in adult life, especially anxiety and
A review by Weems (2008) describes some depressive disorders. This chapter has necessarily
inconsistencies across different research studies. presented a succinct review of a vast topic. The
For example, prospective longitudinal studies of changing classifications require clinicians to be
childhood anxiety disorders have reported estimates familiar with diagnostic criteria in order to detect
of stability from 4 to 80%. These studies may show these disorders, which are so often comorbid with
wide variability for many reasons (e.g. disorder type, other childhood psychiatric presentations. Research
age at onset, the informant, the sample, and the evidence is accumulating about the aetiology
method and duration of assessment). Age at onset of these conditions, the contribution of genetics
may be a significant factor, since there are specific and environmental events, and the influence of
age differences in the predominant expression of the parent and family interactions. Insights into the
symptoms of childhood anxiety: epidemiological neuroimaging and neuropsychological findings
data on the age at onset of anxiety disorders are are intriguing. Increasing our understanding of
generally consistent with the normative trajectories evidence-based interventions, including the role of
of fear development (Tables 2 and 3). psychopharmacology, is essential so that targeted
Concerning the prediction of adult-onset anxiety interventions can be used to inform and support
disorders, studies often point to little specificity. The families and improve children’s symptoms.
342 BJPsych Advances (2016), vol. 22, 335–344 doi: 10.1192/apt.bp.114.014183Anxiety disorders in children and adolescents
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MCQs 3 As regards CBT for paediatric anxiety b apprehension of novel situations, with
Select the single best option for each question stem disorders, it is not true that: raised reactivity of the sympathetic nervous
a components may include reframing, systematic system
1 Fear of the dark is most commonly desensitisation, and exposure and response c distress at the absence of the primary care-
observed in children aged: prevention giver, with increased cortisol levels
a 9 months to 3 years b there is evidence for efficacy of group-delivered d a marked fear of strangers, with increased
b 3–6 years CBT activity in the left dorsolateral prefrontal
c 6–9 years c it specifically references psychological processes cortex
d 9–12 years such as projection, displacement and acting out e disregard for apparent danger, with increased
e 12–15 years. d it is recommended by NICE guidelines activity in the HPA axis.
e there is evidence for efficacy of computerised
2 The prevalence of panic disorders in late CBT. 5 Which of the following medications is
teens is: currently licensed for paediatric OCD?
a 0.5% 4 An inhibited temperament has been a Buspirone
b 1% defined by Kagan et al as: b Fluoxetine
c 2.5% a a disinterest in new experiences, with c Sertraline
d 5% suppression of the parasympathetic nervous d Risperidone
e 10%. system e Escitalopram.
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