SPECIAL ARTICLE

This is the third in a series of1O-year updates in child and adolescent psychiatry. Topics are selected in consultationwith theAA CAP Committee on Recertification, bothfor the importance ofnew research and its clinicalor developmentalsignificance. The authors have been asked to place an asterisk before the five or six most seminal references.

J McD.

Anxiety Disorders in Children and Adolescents:A Review of the Past 10 Years

GAIL A. BERNSTEIN, M.D., CARRIE M. BORCHARDT, M.D., AND AMY R. PERWIEN, B.A.

ABSTRACT

Objective: To critically review the research on anxiety disorders in children and adolescents, focusing on new develop­

ments in the past 10 years. Method: This review includes recent articles which contribute to the conceptualization,

assessment, and treatment of childhood anxiety disorders. Results: Information was organized into a developmental

framework. Anxiety disorders research has shown steady progress. Conclusions: More research is needed, particularly

in the areas of neurobiological basis of anxiety disorders, longitUdinal studies, and treatment. J. Am. Acad. ChildAdo/esc.

Psychiatry, 1996, 35(9): 1110-1119. Key Words: anxiety disorders, anxiolytics.

With the arrival of DSM-IV (American PsychiatricAssociation, 1994), anxiety disorders in children andadolescents are defined quite differently. The onlydisorder remaining of the three anxiety disorders ofchildhood and adolescence in DSM-III-R (AmericanPsychiatric Association, 1987) is separation anxietydisorder. Most cases of overanxious disorder will nowbe subsumed under generalized anxiety disorder, andavoidant disorder has been conceptualized as socialphobia.

These changes may prove advantageous. Researchwill now concentrate on disorders seen in both childrenand adults, therefore decreasing the developmental gapfrom earlier investigations (Bernstein and Borchardt,

Accepted September 7. 1995.Dr. Bernstein is Associate Professor and Director and Dr. Borchardt is

Associate Professor and Director of InpatientServices, Division of Child andAdolescent Psychiatry, University ofMinnesota MedicalSchool Minneapolis.Ms. Penoien is a graduate studentin the Department ofClinicaland HealthPsychowgy, University ofFlorida, Gainesville.

Dr. Bernstein seffort on this manuscript wassupported in part by NIMHgrantR29MH46534. Theauthors acknowledge LoisLaitinen, MB.A., MM,for manuscript preparation.

Reprintrequests toDr. Bernstein, Division afChildandAdolescentPsychiatry,Box 95 UMHG, 420 Delaware StreetSE, Minneapolis, MN 55455.

0890-8567/96/3509-1110$03.00/0©1996 by the American Academyof Child .and Adolescent Psychiatry.

1991). This article reviews what is known about anxietydisorders in childhood and adolescence, focusing onthe literature of the past 10 years. Information ispresented from a developmental perspective.

EPIDEMIOLOGY

Severalepidemiological studies indicate a high preva­lence of anxiety disorders in nonreferred children. Ina sample of792 eleven-year-olds, Anderson et al. (1987)found the following rates of anxiety disorders: 3.5%for separation anxiety disorder, 2.9% for overanxiousdisorder, 2.4% for simple phobia, and 1.0% for socialphobia. Bowen et al. (1990) reported a 3.6% prevalenceof separation anxiety disorder and a 2.4% prevalenceof overanxious disorder in a sample of 12- to 16-year­olds (N = 1,869). In 14- to 17-year-olds (N = 5,596),the lifetime prevalence for panic disorder was 0.6%and for generalized anxiety disorder was 3.7% (Whit­aker et al., 1990).

A pediatric primary care sample of 7- to l I-year­old children (N = 300) revealed a I-year prevalenceof anxiety disorders of 15.4% based on combiningdiagnoses from parent and child structured psychiatricinterviews. Simple phobia, separation anxiety disorder,and overanxious disorder were the most prevalent, with

1110 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996

rates of 9.2%, 4.1%, and 4.6%, respectively (Benjaminer al., 1990).

ANXIETY IN INFANTS AND PRESCHOOL CHILDREN

Temperament

The relationship between early temperamental traitsand the predisposition to the development ofexternaliz­ing and internalizing symptoms has been examinedlongitudinally in more than 800 children over a 12­year period (Caspi et al., 1995). Boyswho were charac­terized as confident and as eager to explore novelsituations at 5 years of age were significantly less likelyto manifest anxiety in childhood and adolescence. Girlsat ages 3 and 5 years who were passive, shy, fearful,and avoided new situations were significantly morelikely to exhibit anxiety at later ages. Thus, it appearsthat temperamental traits are related to later reportsof anxiety in both boys and girls.

Merging the concepts of temperament and neurobi­ology has led to the exciting findings related to behav­ioral inhibition in young children. Behavioralinhibitionto the unfamiliar (a laboratory-based temperamentalconstruct) has been studied prospectively in youngchildren (Kagan et al., 1988). This temperamentalcharacteristic is defined as the tendency to be unusuallyshy or to show fear and withdrawal in novel and/orunfamiliar situations.

Two independent cohorts of preschool childrenclassified as behaviorally inhibited or uninhibited at21 or 31 months have been followed longitudinallyby Kagan and colleagues (1988). The researchers havefound that the tendency to approach or withdraw fromnovelty is an enduring, temperamental trait. Childrenwith behavioral inhibition are differentiated from thosewithout behavioral inhibition, not only on behaviorbut on physiological markers including higher, stableheart rate and acceleration of heart rate with tasksrequiring cognitive effort. Other neurophysiologicalcorrelates of behavioral inhibition have included in­creased tension in the larynx and vocal cords, elevatedsalivary cortisol levels, elevated urinary catecholamines,and larger pupillary dilation during cognitive tasks.

A 3-year follow-up study found evidence that chil­dren initially identified as having behavioral inhibitioncompared with those not initially classified as behavior­ally inhibited were significantly more likely to havemultiple psychiatric disorders and to have two or more

ANXIETY DISORDERS REVIEW

anxiety disorders (Biederman et al., 1993). Specifically,avoidant disorder, separation anxiety disorder, and ago­raphobia were significantly more prevalent in the groupwith behavioral inhibition. The rates of all anxietydisorders in the inhibited children increased markedlyfrom baseline to follow-up. Therefore, behavioral inhi­bition appears to be a risk factor for the developmentof anxiety disorders in young children.

Attachment

An innovative study of mothers with anxiety disor­ders (n = 18) and their preschool children (n = 20)examined mother-child attachment patterns (Manassiset al., 1994). Mothers included 14 with panic disorder,3 with generalized anxiety disorder, and 1 with obses­sive-compulsive disorder. All mothers were classifiedas nonautonomous (i.e., insecure) in their current andpast attachment relationships. Eighty percent of theirpreschool children were insecurely attached as deter­mined with the Strange Situation Procedure (Ainsworthand Wittig, 1%9). Three preschool children met crite­ria for an anxiety disorder; all three were insecurelyattached. Thus, insecure attachment may be a risk factorfor the development of childhood anxiety disorders.

Despite having mothers with nonautonomous at­tachment histories, 20% of the preschool childrenwere securely attached. This suggests the presence ofprotective factors that help establish and maintainsecure attachments. For example, mothers of securelyattached preschool children were less likely to reportdepressive symptoms, had experienced fewer recentstressful life events, and reported feeling more compe­tent in parenting.

Sixty-five percent of the preschool children matchedtheir mothers' specific attachment classifications, illus­trating that a mother's attachment pattern may berepeated in the offspring's pattern of attachment withher. A criticism of this study, which should be correctedin future investigations, is that raters of attachmentwere not blind to maternal diagnosis, which may haveintroduced a bias when coding attachment patterns.Replication of this work with a larger sample size,aswellas following the children longitudinally, is warranted.

Manassis and colleagues (1995) also reported that65% of the 20 preschool children were classified asbehaviorally inhibited. The presence of behavioral inhi­bition did not appear to increase the risk of being

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996 1111

BERNSTEIN ET AL.

insecurely attached and vice versa. The possible inter­play between behavioral inhibition and insecure attach­ment pattern and how this might contribute to thedevelopment of anxiety in young children could notbe answered in the study.

Infants who are ambivalently attached (i.e., a typeof insecure attachment) have more anxiety diagnoses inchildhood and adolescence (Warren, Huston, Egeland,and Sroufe, personal communication, 1996). In thislongitudinal study, attachment was measured at 12months with the Strange Situation Procedure andanxiety disorders at 17 years with a semistructuredpsychiatric interview.

Neither temperament theory nor attachment theoryalone accounts for the development ofanxiety disorders(Manassis and Bradley, 1994a). An integrated modelwhich incorporates temperament, attachment pattern,and other influences (e.g., cognitive factors, develop­mental events, traumatic events, access to support sys­tems) has been proposed by Manassis and Bradley(1994a).

ANXIETY IN CHILDREN

One of the dilemmas in anxiety disorder researchand in clinical practice is to define what constitutesan anxiety disorder, in comparison with normal anxiety.Bell-Dolan et al. (1990), who examined the prevalenceof anxiety symptoms in 62 nonreferred children witha semistructured psychiatric interview, found that iso­lated subclinical anxiety disorder symptoms were com­mon. From 9.8% to 30.6% of the nonreferred childrenreported subclinical levels of individual overanxiousdisorder symptoms and 10.7% to 22.6% endorsedsubclinical phobias. The most commonly endorsedanxiety symptoms were overconcern about competence,excessive need for reassurance, fear of the dark, fearof harm to an attachment figure, and somatic com­plaints. In general, girls endorsed more anxiety symp­toms than boys and younger children were more likelyto experience symptoms, particularly separation anxietysymptoms, than older children.

Some children without an anxiety disorder experi­ence difficulty functioning as a result of their anxietysymptoms (American Academy of Child and Adoles­cent Psychiatry, 1993). Thus, anxiety symptoms maybe more than a transient developmental phenomenon.

In an epidemiological study of 1,197 first-grade chil­dren, Ialongo and colleagues (1994) found that self­reported anxiety symptoms were moderately stable overa 4-month period. Anxiety was significantly associatedwith lower achievement; children with high levels ofanxiety were 7.7 and 2.4 times more likely to be inthe lowest quartile of reading and math achieve­ment, respectively.

After following the children over 4Yz years, Ialongoand colleagues (1995) found that anxiety in first gradesignificantly predicted anxiety in fifth grade. In addi­tion, anxiety symptoms contributed significantly tofifth-grade achievement test scores. Specifically, firstgraders in the upper third of self-reported anxietysymptoms were approximately 10 times more likely to

be in the lower third of achievement in fifth grade.The findings of these studies suggest the importanceofnot discounting symptoms as short-lived or insignifi­cant in young children.

The most common anxiety disorders of middle child­hood include separation anxiety disorder, overanxiousdisorder, and specific phobias. According to DSM-IV,the core feature of separation anxiety disorder is markedanxiety about separation from significant others orfrom home which is beyond that expected for the child'sdevelopmental level (American Psychiatric Association,1994). DSM-III-R defined the essential feature of over­anxious disorder as marked, unrealistic worry about avariety of situations (American Psychiatric Associa­tion, 1987).

DSM-IV defines a specific phobia (formerly knownas simple phobia) as an excessive and unreasonablefear of circumscribed objects or situations where theavoidance, anxiety, or distress related to the fear isassociated with functional impairmenr or significantdistress (American Psychiatric Association, 1994). Un­like adults, children may not realize that their fearsare marked or unreasonable. Children with specificphobias report extreme fear or dread, physiologicalreactions, and avoidance or fearful anticipation whenconfronted with the phobic stimulus (Silverman andRabian, 1993).

Sociodemographic characteristics in a large clinicsample (N = 188) of children with anxiety disorderswere examined by Last et al. (1992). The childrenwith separation anxiety disorder had the earliest ageof onset (mean = 7.5 years) and the youngest age atintake (mean = 10.3 years) compared with children

1112 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996

with other anxiety disorders. The gender ratio for eachanxiety disorder was relatively equal. Most of thechildren were from middle class to upper middle classbackgrounds and from intact families, with the excep­tion of those with separation anxiety disorder whowere more commonly from single-parent and low socio­economic status homes.

Selective mutism, which is classified in DSM-IVunder "other disorders of infancy, childhood, or adoles­cence" (American Psychiatric Association, 1994), hasrecently been conceptualized as a type of social phobia(Black and Uhde, 1995). The hallmark of this disorderis the failure to talk in specific social situations, forexample the classroom, while talking in other settings,such as at home (American Psychiatric Association,1994). Black and Uhde (1995) systematicallyevaluatedchildren (7.3 ::!: 2.8 years) with selective mutism (N =

30) and found that 90% met diagnostic criteria forsocial phobia exhibited in ways other than reluctanceto speak. Parent and teacher ratings showed high levelsofsocial anxiety, without prominent elevations of otherpsychiatric symptoms. Although this study had severalmethodological limitations including diagnoses basedon parent interview only, lack of a control group, andall clinical interviews completed by the same clinician,the findings suggest that selective mutism should beviewed as a subtype of social phobia rather than as adistinct disorder.

ANXIETY IN ADOLESCENTS

Sources of anxiety for normal adolescents includeconsolidation of identity, sexuality, social acceptance,and independence conflicts. When anxiety disordersymptoms in normal adolescents were examined witha semistructured psychiatric interview, the symptomsthat were more commonly reported by adolescentsthan preadolescents included fears of heights, publicspeaking, blushing, excessive worry about past behavior,and self-consciousness (Bell-Dolan et al., 1990).

Adolescents can present with the same anxiety disor­ders that children present with (see previous section).In addition, in the peripubertal period, individualsbegin to develop vulnerability to other anxiety disordersincluding panic disorder, agoraphobia, and socialphobia.

DSM-IV includes the diagnoses of panic disorderwith or without agoraphobia, and agoraphobia withour

ANXIETY DISORDERS REVIEW

history ofpanic disorder (American Psychiatric Associa­tion, 1994). The criteria for a panic attack include adiscrete episode of marked fear in which at least 4 outof 13 physical and psychological symptoms occur. Thecriteria for agoraphobia include fear of being unableto escape from places in which the individual mayexperience a panic attack or where help may be unavail­able if a panic attack occurs (American PsychiatricAssociation, 1994).

Panic disorder is uncommon before the peripubertalperiod (Black and Robbins, 1990; Klein et al., 1992).Yet retrospective reports of adults have shown panicdisorder most commonly begins by adolescence oryoung adulthood (Moreau and Follett, 1993). TheNational Institure of Mental Health EpidemiologicCatchment Area Program found the peak age of onsetfor panic disorder was 15 to 19 years (Von Korff et al.,1985); however, this also was based on retrospectivereports.

Hayward and colleagues (1992) studied 754 sixth­and seventh-grade girls to determine whether there wasan association between the occurrence of panic attacksand pubertal stage, independent of age. Results showed5.3% of the sample overall reported a history of atleast one 4-symptom panic attack. None of the 94subjects who were at Tanner stage 1 or 2 reportedpanic attacks. Rates of panic attacks increased withincreasing sexual maturity, up to a rate of 8% forsubjects who were at Tanner stage 5. The' increasingrates of reported attacks were not accounted for byincreasing age. This study is an excellent example ofwhy panic disorder in young people deserves moreresearch attention. Research in adults has shown panicdisorder to be linked to neurobiological factors (Salleeand Greenawald, 1995). While spontaneous panic at­tacks are rare before pubertal changes begin, adolescenceis the peak period for onset of the disorder. Prospectivestudies of children and adolescents are needed to pro­vide clues to the biological changes involved in theacquired vulnerability to panic disorder.

Agoraphobia has not been rigorously studied inchildren and adolescents. Studies of adults with agora­phobia have looked for childhood antecedents, particu­larly separation anxiety disorder. Klein (1964), on thebasis of retrospective histories of childhood separationanxiety in adults with agoraphobia, hypothesized thatchildhood separation anxiety could evolve into agora­phobia in adulthood. However, a review of studies

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996 1113

BERNSTEIN ET AL.

that examined the association of separation anxiety inchildhood with subsequent outcomes in adulthoodfound that childhood separation anxiety is a nonspecificprecursor to a number of adult psychiatric conditionsincluding depression, as well as any anxiety disorder(Moreau and Follett, 1993).

A recent study of 194 adults with panic disordershowed that 54% retrospectively reported a history ofchildhood anxiety disorder (Pollack et al., 1996). Thosewith a history of anxiety disorder in childhood, com­pared to those without this history, were significantlymore likely to have comorbid other anxiety and de­pressive disorders as adults. Of those adults with ahistory of anxiety disorders, 64.8% had had two ormore anxiety disorders as children.

The essential features of social phobia include exces­sive anxiety about social or performance situations inwhich the individual fears scrutiny or exposure tounfamiliar persons (American Psychiatric Association,1994). In children, the ability for age-appropriate rela­tionships with familiar people must be evident andthe anxiety occurs in peer situations. Although socialphobia occurs in preadolescents, onset most commonlyoccurs in early to midadolescence (Schneier et al.,1992; Strauss and Last, 1993).

Similar numbers of males and females develop socialphobia. Comorbidity with other anxiety disorders andaffective disorders is common. In a clinic sample,Strauss and Last (1993) found 66% of social phobicsubjects had concurrent anxiety disorders, and 17%had a concurrent affective disorder. Individuals withthe DSM-III-R diagnosis of avoidant disorder weresimilar to those with social phobia in sociodemographicand comorbidity patterns (Francis et al., 1992; Lastet al., 1992). However, the age of onset is different,with avoidant disorder presenting at an earlier age thansocial phobia (Francis et al., 1992). This fits withavoidant disorder and social phobia as the same disorderon a developmental continuum. In normal develop­ment, fear of unfamiliar people occurs earlier thansocial-evaluative fears. Thus, there was little evidenceto support avoidant disorder as a separate entity. Thisled to the conceptualization of avoidant disorder associal phobia in DSM-IV.

DSM-IVgeneralized anxiety disorder is characterizedby excessive worry about a variety of situations (Ameri­can Psychiatric Association, 1994). The individual finds

it hard to control the anxiety. DSM-III-R criteria foroveranxious disorder were found to be vague, nonspe­cific, and to overlap with criteria of other disorders(Beidel, 1991; Werry, 1991). These were some of thereasons for elimination of this disorder in DSM-IV.In DSM-IV, overanxious disorder is included undergeneralized anxiety disorder. The criteria for generalizedanxiety disorder in DSM-IVare modified for childrenso that only one of the six accompanying symptomsis required.

However, generalized anxiety disorder in childrenand adolescents has not been well researched. In ananxiety disorders clinic sample, none of the 188 chil­dren and adolescents fulfilled DSM-III-R criteria forgeneralized anxiety disorder (Last et al., 1992). Further­more, family history data, as well as data from aprospective study of children with anxiety disorders,have not provided strong support for a link betweenoveranxious disorder and generalized anxiety disorder(Last, 1993). Future studies will determine the applica­bility of current criteria for generalized anxiety disorderto children and adolescents.

ASSESSMENT OF ANXIETY

The "Practice Parameters for the Assessment andTreatment of Anxiety Disorders" (American Academyof Child and Adolescent Psychiatry, 1993) note im­portant areas to emphasize in the assessment of anxietydisorders in children and adolescents. The onset, devel­opment, and context of anxiety symptoms, as wellas information regarding the child's or adolescent'sdevelopmental, medical, school, and social history, anda family psychiatric history should be obtained. Mentalstatus examination and assessment of school function­ing are critical.

For the assessment of anxiety, structured psychiatricinterviews, clinician rating scales, self-report instru­ments, and parent report measures are available (Table1). It is useful to incorporate several types of instru­ments. Because of the subjective nature of anxietysymptoms, it is important to include measures thatassess anxiety through the child or adolescent's view­point. Since there is often low concordance betweenchild and parent reports of anxiety (Klein, 1991),parental reports offer an additional perspective. How­ever, Frick and colleagues (1994) found that mothersoverreport anxiety symptoms in their children related

1114 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996

ANXIETY DISORDERS REVIEW

TABLE 1Instruments for Assessment of Anxiety in Children and Adolescents

Measure Type of Measure Informant

Schedule for Affective Disorders and Schizo­phrenia for School-Age Children (Cham­bers et al., 1985)

Anxiety Disorders Interview Schedule for Chil­dren (Silverman and Nelles, 1988)

Diagnostic Interview for Children and Adoles­cents-Revised (Welner et al., 1987)

NIMH Diagnostic Interview Schedule forChildren (Shaffer et al., 1996)

State-Trait Anxiety Inventory for Children(Spielberger, 1973)

Revised Children's Manifest Anxiety Scale(Reynolds and Richmond, 1978)

Revised Fear Survey Schedule for Children(Ollendick, 1983)

Visual Analogue Scale for Anxiety-Revised(Bernstein and Garfinkel, 1992)

Social Anxiety Scale for Children-Revised (La­Greca and Stone, 1993)

Multidimensional Anxiety Scale for Children(March, 1996)

Hamilton Anxiety Rating Scale (Hamilton,1959)

Anxiety Rating for Children-Revised (Bern­stein er al., 1996)

Personality Inventory for Children (Wirt etal., 1977)

Child Behavior Checklist (Achenbach, 1991)

Semistructured psychiatric interview; in­formation from all available sourcesused to derive a summary score

Semistructured psychiatric interview in­cludes other disorders bur focuses onanxiety disorders

Structured psychiatric interview

Highly structured psychiatric interview;designed for lay interviewers

Severity measure assesses state and traitanxiety

Severity measure with three anxiety sub­scales and a Lie subscale

Severity measures examines fears

Visual analogues to quantify anxiety re­lated to anxiety-producing situations

Severity measure of social anxiety

Severity measure with four main anxietyfactors

Clinician rating scale for adults that hasbeen validated for adolescents (Clarkand Donovan, 1994)

Clinician rating scale assesses severity;has Anxiety subscale and Physiologicalsubscale

Multiple scales including Anxiety scale

Multiple scales including Anxious/De­pressed scale

Parent and child; epidemiological versionavailable (K-SADS-E) (Orvaschelet al., 1982)

Parent and child versions

Parent, child, and adolescent versions

Parent and child versions

Self-report

Self-report

Self-report

Self-report

Self-report

Self-report

Clinician rating using adolescent report

Clinician rating using child or adolescentreport

Parent report

Parent report

Note: NIMH = National Institute of Mental Health.

to increased level of maternal anxiety. This highlightsthe importance of clinician awareness of parental anxi­ety level. Clinician rating scales are useful because theyintegrate the clinician's expertise and the child oradolescent's report of anxiety symptoms. Finally, it isuseful to combine a structured psychiatric interviewwhich will provide diagnoses, with ratings of the severityof the anxiety symptoms.

There are several limitations of anxiety scales. Onedifficulty is the overlap of symptoms on self-reportmeasures ofanxiety and depression (Brady and Kendall,

1992). Furthermore, although the state versus traitdichotomy of anxiety has been considered, it has notyet been well differentiated with rating scales (Stallingsand March, 1995). As noted in Table 1, only theState-Trait Anxiety Inventory for Children (Spiel­berger, 1973) was specifically developed to examineboth state and trait anxiety.

LONGITUDINAL STUDIES

Prospective, longitudinal studies are needed to deter­mine whether anxiety disorders in children and adoles-

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BERNSTEIN ET AL.

cents are persistent and to determine how the symptomslook at different stagesof development. Severalprospec-

- tive studies are beginning to emerge. Cantwell andBaker (1989) studied young children with speech andlanguage disorders. For those with anxiety disorders,the remis~ion rate of anxiety disorder at 4- to 5-yearfollow-up was 77%.

A 3- to 4-year follow-up of referred children andadolescents with anxiety disorders (N = 102) showeda high remission rate, with 82% no longer meetingcriteria for their initial anxiety disorder (Last et al., inpress). Of those who went into remission, the majority(68%) did so during the first year of follow-up. Of theanxiety disorders examined, separation anxiety disorderhad the highest recovery rate at 96%, with panicdisorder having the lowest rate of remission at 70%.Early age of onset and older age at intake were factorspredicting slower recovery. Overanxious disorder wasthe slowest to remit. During the follow-up period,30% of the children with anxiety disorders developednew psychiatric disorders, and half of these childrendeveloped new anxiety disorders.

Cohen and colleagues (1993) prospectively followedan epidemiological sample of 734 children aged 9 to18 years. The likelihood of having the same disorderrediagnosed at follow-up was higher if symptoms atbaseline assessment were severe. For overanxious disor­der, the only anxiety disorder studied, 47% of severecaseswere rediagnosed at 2Y2-year follow-up. Therefore,nonreferred children may have persistence of symp­toms. More studies that follow youths with anxietydisorders prospectively throughout childhood and ado­lescence and into adulthood are needed.

TREATMENT OF INFANTS AND PRESCHOOL

CHILDREN

Since an insecure bond between parent and childmay be an important factor in the development ofanxiety symptoms in infants and preschool children,treatment aimed at improving the interactions betweenparent and child may be crucial. "Helping anxiousadults resolve the losses and traumatic experiencesof the past may indirectly benefit their children byimproving the parent-child attachment relationship. . . reducing stressful life events, and increasing theirsense of competence as parents may also help theseindividuals develop secure attachment relationshipswith their children" (Manassis et al., 1994, p. 1111).

Working with parents or the parent-child dyad maybe more preventive of anxiety and anxiety disordersthan treating preschool children individually. More­over, attending to temperamental factors may alsobe preventive.

TREATMENT OF CHILDREN AND ADOLESCENTS

In general, a multimodal approach is incorporatedin the treatment of a child or adolescent with ananxiety disorder. The "Practice Parameters for theAssessment and Treatment of Anxiety Disorders" rec­ommends that, when developing a treatment plan,consideration be given to the following components:feedback and education to the parents and child aboutthe specific disorder, consultation to primary carephysicians and school personnel, cognitive-behavioralinterventions, psychodynamic psychotherapy, familytherapy, and pharmacotherapy. The Practice Parame­ters recommends some specific interventions for specificanxiety disorders; for example, a plan for separation(e.g., return to school) for children with separationanxiety disorder and systematic desensitization andexposure for specific phobia.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy integrates behavioralapproaches (e.g., exposure) and cognitive techniques(e.g., coping self-statements). Cognitive techniques em­phasize restructuring anxious thoughts into a morepositive framework, resulting in more assertive andadaptive behaviors (Leonard and Rapoport, 1991).Children aged approximately 10 years and older canbenefit from cognitive techniques.

Kendall (1994) compared 16 weeks of cognitive­behavioral therapy versus 8 weeks ofwaiting-list controlfor 47 children (aged 9 to 13 years) with anxietydisorders. The cognitive-behavioral package includedcoping self-statements, modeling, exposure, role-play­ing, relaxation training, and contingent reinforcement.A greater number of treated subjects than waiting­list controls reported clinically significant decreases inanxiety and depression after the intervention. Manysubjects receiving cognitive-behavioral therapy did notmeet criteria for an anxiety diagnosis posttreatmentand at l-year follow-up.

Psychodynamic Therapy

Psychodynamic psychotherapy is an outgrowth ofpsychoanalysis (Bemporad, 1991). This approach fo-

1116 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996

cuses on underlying fears and anxieties. Importantthemes in treating children with anxiety disorders in­clude resolving issues of separation, independence, andself-esteem (Leonard and Rapoport, 1991).

Two studies support the use of psychodynamic psy­chorherapy in children with anxiety disorders. A treat­ment study of 7- to 10-year-old boys (N = 12) withoveranxious disorder and learning difficulties comparedweekly, four times per week, and weekly followed byfour times per week psychodynamic psychotherapy(Heinicke and Ramsey-Klee, 1986). Boys seen moreoften than once a week showed better adaptationand enhanced capacity for relationships at the end oftreatment and 1 year after treatment, and they alsoshowed greater improvement in reading in the yearafter completion of treatment.

In a retrospective chart review of 352 children as­signed DSM-III-R diagnoses, primarily anxiety and/ordepressive disorders, psychotherapy one to three timesper week was compared with psychoanalytic psycho­therapy four to five times per week (Target and Fonagy,1994). Combining the children who received at least6 months of either treatment, 72% showed improve­ment in adaptation. Improvement was predicted byyounger age, presence of phobic symptoms, longerduration of treatment, and more intensive treatment.

Pharmacological Treatment

While anxiety disorders is one of the most prevalentcategory of psychopathology in children and adoles­cents, the studies evaluating pharmacological treat­ments for these disorders are scarce. In general, thesample sizes of these studies have been small and theplacebo response rates are high. Both of these factorslimit the likelihood of finding significant differencesbetween antianxiety medication and placebo in treatinganxiety symptoms.

Commonly considered medications for anxietysymptoms include tricyclic antidepressants and benzo­diazepines. A third consideration is the serotonin reup­take inhibitors. Other choices are ~-blockers ,

buspirone, and monoamine oxidase inhibitors (Allenet al., 1995, for recent review).

Four double-blind, placebo-controlled studies of tri­cyclic antidepressants for school refusal associated withanxiety show contrasting results (Berney et al., 1981;Bernstein et al., 1990; Gittelman-Klein and Klein,1973; Klein et al., 1992). The conflicting findings

ANXIETy DISORDERS REVIE W

most likely are explained by differences in dosages,diagnostic comorbidity patterns, duration of treatment,and concurrent therapy. Case reports support the useof tricyclic antidepressants for children and adolescentswith panic disorder (Black and Robbins, 1990; Garlandand Smith, 1990).

In an open-label study (Simeon and Ferguson, 1987)followed by a double-blind placebo-controlled study(Simeon et al., 1992), results (although not statisticallysignificant) suggested that alprazolam may be usefulin allaying anxiety symptoms in children with overanxi­ous or avoidant disorders. In a double-blind crossoverstudy, Graae and colleagues (1994) evaluated clona­zepam versus placebo in children with anxiety disorders(primarily separation anxiety disorder). Nine of 12subjects showed moderate to marked improvementwith clonazepam and 6 of 12 no longer met criteriafor anxiety disorder at the end of the study.

In addition, studies are emerging that support benzo­diazepines for teenagers with panic disorder. Four ado­lescents with panic disorder were successfully treatedwith clonazepam in an open-label trial (Kutcher andMackenzie, 1988). The frequency of panic attacks andbaseline level of anxiety decreased. In a double-blind,placebo-controlled study, adolescents receiving clona­zepam showed decreases in the number ofpanic attacks,in anxiety scores, and on a school and social impairmentscale (Kutcher and Reiter, personal communication,1996).

Selectiveserotonin reuptake inhibitors are now beingconsidered for the treatment of childhood anxietydisorders. Five children with anxiety disorders receivedat least 6 weeks of fluoxetine in open-label trials (Man­assis and Bradley, 1994b). All five showed a decreasein anxiety symptoms per self-report and parental report.An open-label study of fluoxetine in 21 children withseparation anxiety disorder, social phobia, or overanxi­ous disorder showed 81% had moderate to markedimprovement (Birmaher et al., 1994). Benefit wasappreciated after 6 to 8 weeks of treatment. A 12-weekdouble-blind, placebo-controlled study of fluoxetinein 15 children with selective mutism demonstratedsignificant improvement on parental ratings of anxietyand mutism in the fluoxetine group (Black and Uhde,1994). Yet children in both the imipramine and Huoxe­tine groups remained symptomatic at the end of thestudy.

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BERNSTEIN ET AL.

Anxiolytics may be considered as part of amultimodal treatment plan. Medications are morelikely to be considered in older children and adolescentsand in those with severe symptomatology. Diagnosticcomorbidity and side effects profile are important fac­tors in the selection of the class of antianxiety medica­tion (Bernstein, 1994).

CONCLUSIONS

Dramatic discoveries have included the identificationof behavioral inhibition as an early and persistenttemperamental risk factor associatedwith neurobiologi­cal markers, which predicts the later development ofprepubertal anxiety disorders. Other exciting advancesinclude the conceptualization of selective mutism as atype of social phobia and the recognition that thevulnerability to panic disorder is a function of pubertalchanges, thus lending support to the biological basisof this disorder. The development of practice parame­ters, of focused, specific cognitive-behavioral packagesfor the treatment of anxiety disorders, and the earlyinvestigation of selective serotonin reuptake inhibitorsfor targeting anxiety are highlights in the treatmentarena. Areas for future research include the neurobiolog­ical basisofanxiety disorders (especially panic disorder),longitudinal studies, and investigation of combinedtreatments.

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