Anxiety Disorders

Anxiety disorders include separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, agoraphobia, panic disorder with and without agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorder not otherwise specified. Common features shared across anxiety disorders include (1) avoidance of feared objects, situations, or events, or enduring such objects, situations, events with severe distress; (2) maladaptive thoughts or cognitions, typically regarding harm or injury to oneself or loved one; and (3) physiological arousal or reactions (e.g., palpitations, sweating, irritability). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994), with the exception of the anxiety disorder specific to childhood, separation anxiety disorder, the same criteria are applied for diagnosing anxiety disorders in adults and children. For all anxiety disorders, symptoms must be present for a specific time period (at least four weeks for separation anxiety disorder; six months for all other anxiety disorders), be age inappropriate, and interfere with an individual's functioning.

Ethnic and Cultural Variations

Epidemiological studies of anxiety disorders in children have rarely been conducted using diverse ethnic or racial groups. Hector R. Bird and his colleagues (1988) conducted a community study of behavioral and emotional problems in youth aged four to sixteen years in Puerto Rico. Prevalence rates for the most common anxiety disorders were 2.6 percent for specific phobia and 4.7 percent for separation anxiety disorder.

Glorisa Canino and her colleagues (1986) compared rates of anxiety symptoms (not diagnoses) in an outpatient clinic sample of African-American and Hispanic youth (aged five to fourteen years). Hispanic children were found to present with more symptoms of fears, phobias, anxiety, panic, school refusal, and disturbed peer relationships than African-American children. C. G. Last and S. Perrin (1993) compared African-American and Euro-American children (aged five to seventeen years) who were referred to a childhood anxiety disorders specialty clinic, and found no significant differences between the two groups in lifetime prevalence rates of anxiety diagnoses. Golda Ginsburg and Wendy Silverman's (1996) comparison of Hispanic and Euro-American children (aged six to seventeen years) who were referred to a childhood anxiety disorders specialty clinic indicated that the two groups were more similar than different on the main variables examined, including mean age at intake, family income, mean ratings of impairment of diagnoses (0-9 point scale), school refusal behavior, and number of co-occurring diagnoses. More research is needed on the expression of anxiety disorders using ethnically and culturally diverse samples of children.

Biological Factors

Evidence for biological factors that predispose children to anxiety disorders is based largely on findings from family aggregation, twin, behavioral genetic, and behavioral inhibition studies. Family aggregation studies suggest that children whose parents have an anxiety disorder are at risk for developing an anxiety disorder themselves (Biederman et al. 2001). Similarly, parents whose children have an anxiety disorder are likely to show anxiety disorders or symptoms themselves. Research on family aggregation also suggests that when parents have an anxiety disorder, mothers are more often associated with familial transmission of anxiety than fathers. Also, children of anxious parents are likely to have an earlier onset for anxiety disorders than their parents.

Twin studies also suggest a familial transmission. For example, concordance rates from different monozygotic (identical) and dizygotic (fraternal) twin pairs suggest a strong genetic basis for anxiety neurosis. Thalia C. Eley's (1999) review of behavioral genetic research concluded that factors in shared and nonshared environments of parents with anxiety disorders have an important influence on the development and maintenance of most anxiety disorders in their children and adolescents.

Recent research on behavioral inhibition and anxiety has provided important neurobiological insights regarding correlates in the etiology of anxiety disorders (Sallee and Greenawald 1995). Behavioral inhibition refers to the temperamental style of approximately 10 to 15 percent of Euro-American infants who are predisposed to being irritable, shy, and fearful as toddlers, and cautious, quiet, and introverted as school-aged children (e.g., Kagan 1989).

Although family, twin, behavioral genetic, and behavioral inhibition investigations all provide empirical support for biological dispositional factors in the etiology of anxiety disorders in children, the specific mechanism of transmission are unclear. This represents a critical area for further research.

Family Environment and Parenting Factors

Parenting styles of anxious children have been described as overprotecting, ambivalent, rejecting, and hostile (See Ginsburg, Silverman, and Kurtines 1995). Retrospective reports of adults with anxiety disorders show that these adults view their parents as overcontrolling and less affectionate. Studies of families of school-refusing/anxious children indicate that these families score lower on indices of child independence and participation in recreational activities, and higher on indices of hostility/conflict than families of non-school-refusing/anxious children (Kearney and Silverman 1995). These families also have been found to be more overprotective and disturbed in role performance, communication, affective expression, and control relative to families of children with nonanxiety psychiatric disorders (e.g., Bernstein and Garfinkel 1986). In a review of the parenting and child-rearing practices research literature, Ronald Rapee (1997) concluded that rejection and excessive parental control were related to the development and maintenance of anxiety disorders in children. An observational study conducted by Paula Barrett and her colleagues (1996) found that children with anxiety disorders and their parents generated more avoidant solutions in problem-solving situations relative to aggressive and nonclinical controls. These parents also modeled caution, provided information about risks, expressed doubts about child competency, and rewarded avoidant behavior. Moreover, having an anxious family member (e.g., parent) also has been shown to increase risk for distress and dysfunction in family relationships (Bruch and Heimberg 1994). Given the consistency of findings showing the role of the family environment and parenting factors, interventions have been aimed at incorporating these factors in treating children with anxiety disorders.

Family-Focused Interventions

Considerable evidence has accumulated demonstrating the efficacy of individual child cognitive behavior therapy (CBT) for reducing anxiety disorders in children (see Silverman and Berman 2001, for review). In consideration of the accumulating evidence (summarized above), highlighting the importance of the familial context in the development and maintenance of anxiety disorders, early twenty-first century clinical research was directed toward evaluating whether CBT, when used with anxious children, also is efficacious when family parenting variables are targeted in the treatment program. Such work also is a response to increasing interest among practitioners in having available alternative treatment approaches that draw on supplementary therapeutic resources, especially when individual child therapy does not seem sufficient.

As a result, empirical evidence from clinical trials as well as single case study designs suggests that childhood anxiety disorders can be reduced when exposure-based cognitive behavioral treatments target family/parent variables. For example, in a sample of seventy-nine children (ages seven to fourteen years old) and their parents, Paula Barrett, Mark Dadds, and Ronald Rapee (1996) demonstrated that individual cognitive behavioral treatment (ICBT) might be enhanced by parental involvement in the treatment of childhood anxiety disorders when compared to a wait-list comparison group. Results indicated that a large percentage (69.8%) of children who received ICBT, either with or without a parenting component, no longer met diagnostic criteria for an anxiety disorder. Moreover, children who received ICBT with a parenting component had significantly higher treatment success rates (84%) than children who received ICBT without the parenting component (57.1%). Improvement also was evident on child and parent rating scales, though statistically significant differences between the treatment conditions (i.e., ICBT with parent involvement vs. ICBT without parent involvement) were not as apparent on these measures. An interesting age/treatment interaction was observed in that younger children showed more improvement in ICBT with the parenting component than older children who received ICBT without the parenting component.

Barrett and colleagues (2001) reported long-term (five to seven years post-treatment) maintenance of treatment gains from Barrett, Dadds, and Rapee's (1996) study. For both treatment conditions (i.e., ICBT with parental involvement vs. ICBT without parental involvement), treatment gains were maintained for this period as shown by continued absence of the targeted anxiety disorder diagnosis as reported by the child, and on all the child and parent rating scales. The only exception was levels of self-rated fear: children who received ICBT with parental involvement rated significantly less fear at long-term follow-up in comparison to children who received ICBT without parental involvement.

Findings from Vanessa Cobham, Mark Dadds, and Susan Spence (1998) provide additional evidence for ICBT as well as for the involvement of parents in intervention. In this study parental involvement included not only parental management of the child's anxiety, but also parental management of their own anxiety. Children (N=67; ages seven to fourteen years old) with anxiety disorders were assigned to conditions according to whether parents were anxious or not. Treatment success rates for ICBT among children with nonanxious parents were similar to those children with anxious parents who received ICBT plus a parental anxiety management component. Thus, the addition of a parent anxiety management component to ICBT was important for diagnostic recovery for those children with anxious parents.

Barrett (1998) evaluated the effectiveness of including a family component to group CBT. Participants consisted of sixty children (ages seven to fourteen years old) and their parents. Treatment conditions were: (1) child group CBT, (2) child group CBT plus a family management component, and (3) a wait-list control condition. The family management component consisted of parent training of contingency management techniques for their child's anxiety and for any anxiety that parents may experience themselves. Results indicated that children in both group CBT and group CBT plus the family component showed positive treatment in comparison to the wait-list condition. However, children in the group CBT plus family component condition showed somewhat better improvement than children in the group CBT condition as evident in less family disruption, greater parental perception of ability to deal with child's behaviors, and lower child's reports of fear. At one-year follow-up, children in the group CBT plus family maintained lower scores for internalizing and externalizing behaviors as reported by parents. Overall, however, both treatment conditions produced significant change in terms of successful treatment outcome relative to the waitlist condition.

Sandra Mendlowitz and colleagues (1999) conducted a clinical trial examining group CBT for anxiety in children (N=68; ages seven to twelve years old). Three conditions were compared: (1) group CBT for children only, (2) group CBT for children and parents, and (3) group CBT for parents only. A wait-list control condition also was included. Improvement was noted for all treatment conditions in terms of reduction in anxiety symptoms; however, children in the group CBT for children and parents condition showed significantly greater improvement in their coping strategies relative to children in the other conditions.

Susan Spence, Caroline Donovan, and Margaret Brechman-Toussaint (2000) conducted a clinical trial for children with social phobia (N=50; ages seven to fourteen years old) in which group CBT was compared to group CBT with parental involvement, and a wait-list control. Parental involvement consisted mainly of enhanced contingency management techniques taught to parents during therapy sessions. Results indicated that both treatment conditions (i.e., ICBT and ICBT with the parental component) showed significant improvements at post-treatment and twelve-month follow-up when compared to the wait-list condition. It is interesting, however, that comparisons between the two treatment conditions did not show statistically significant differences, suggesting both conditions were efficacious in reducing symptoms of social phobia.

Two late-twentieth-century studies reported on parent and family factors that may be related to treatment success or failure (Berman et al. 2000). Steven L. Berman and his colleagues (2000) found that child symptoms of depression as well as parent self-reported symptoms of depression, fear, hostility, and/or paranoia were predictive of treatment failure. Melissa Crawford and Katharina Manassis (2001) found that child, maternal, and paternal reports of family dysfunction and maternal frustration were significant predictors of a less favorable outcome in child's anxiety and overall functioning. Also, paternal reports of multiple physiological symptoms for which no medical cause was evident were predictive of a less favorable outcome in terms of overall child functioning.

In sum, there is strong and consistent evidence showing a familial influence in the development and maintenance of anxiety disorders. This evidence supports both a biological and psychosocial influence. The intervention research literature further suggests strong evidence for the efficacy of ICBT for reducing anxiety disorders in children. Although the effects might be enhanced when including a family component to the intervention, further research on this issue is needed.

See also:Attachment: Parent-Child Relationships; Chronic Illness; Codependency; Developmental Psychopathology; Disabilities; Parenting Styles; Posttraumatic Stress Disorder (PTSD); School Phobia and School Refusal; Separation Anxiety; Shyness; Substitute Caregivers; Therapy: Couple Relationships

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lissette m. saavedrawendy k. silverman