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Anxiety Disorders and Posttraumatic Stress Disorder Update
Anxiet y Disorders a nd Post tra umatic Stress Disorder Update Andrea M.Victor, PhD*, Gail A. Bernstein, MD KEYWORDS
Pediatric anxiety disorders Separation anxiety disorder Generalized anxiety disorder Social phobia Obsessive-compulsive disorder Posttraumatic stress disorder
Anxiety disorders are one of the most prevalent categories of pediatric psychopathology.1 There is a range of prevalence estimates based on the type of epidemiologic study that is completed. Short assessment intervals and single collection points result in the lowest prevalence estimates. Childhood prevalence studies of having any anxiety disorder show that 3-month estimates range from 2.2% to 8.6%2,3 and 6-month estimates range from 5.5% to 17.7%.4,5 In contrast, retrospective studies with older adolescents and adults that use a lifetime interval typically report higher prevalence estimates. Lifetime prevalence estimates range from 8.3% to 27%.6 Because pediatric anxiety disorders are relatively common, there is an increasing interest in understanding the research and clinical issues related to the presentation and treatment of these disorders. Anxiety disorders are diagnosed throughout the life span. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)7 criteria are similar for youth and adults; however, there are some notable differences that need to be considered when diagnosing anxiety disorders in children and adolescents. Table 1 provides a summary of the differences in diagnostic criteria for pediatric anxiety disorders. SEPARATION ANXIETY DISORDER Clinical Presentation
The key feature of separation anxiety disorder (SAD) is excessive anxiety about separation from primary attachment figures (eg, parents, grandparents). Children with SAD fear that harm will come to themselves or their attachment figures when separated. Other symptoms include distress at the time of separation, somatic complaints
Division of Child & Adolescent Psychiatry, University of Minnesota Medical School, 2450 Riverside Avenue, F256/2B West, Minneapolis, MN 55454, USA * Corresponding author. E-mail address: [email protected] (A.M. Victor). Psychiatr Clin N Am 32 (2009) 57–69 doi:10.1016/j.psc.2008.11.004 0193-953X/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
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Table 1 DSM-IV-TR criteria differences for anxiety disorders in youth Anxiety Disorder
Differences in Criteria forYouth
Generalized anxiety disorder
Requires only one associated symptom.
Social phobia
Children must have the ability to develop age appropriate friendships Children must endorse anxiety with adults and peers Anxiety may be shown through crying, tantrums, freezing, or shrinking from social situations Children do not need to recognize that the fear is excessive or unreasonable
Obsessive-compulsive disorder
Children do not need to recognize that the obsessions and compulsions are excessive or unreasonable
Posttraumatic stress disorder
Response to the traumatic event may be expressed through agitated or disorganized behavior rather than extreme fear, helplessness, or horror Traumatic event may be re-experienced through the use of repetitive play about the trauma Children may have scary dreams without recognizable content that is related to the event Children may re-enact trauma-specific details
when separation occurs or is anticipated, nightmares with themes of separation, shadowing parents in the home, and sleeping with family members.7 Children with SAD commonly refuse to attend school and are reluctant to go other places without their parents. To be diagnosed with SAD, symptoms must be more intense than expected for the child’s developmental level, be present for at least 4 weeks, have an onset before 18 years of age, and cause significant distress or impairment. A distinguishing feature of SAD is that the child’s anxiety is alleviated when with parents, whereas in other anxiety disorders, the presence of an attachment figure has minimal effect on symptom presentation.8 SAD is common in youth with a prevalence rate of 3% to 5%.9,10 It is more likely to occur in children compared with adolescents. Onset is typically at 7 to 9 years of age.9,11 Common comorbid diagnoses include generalized anxiety disorder (GAD), specific phobia, attention-deficit hyperactivity disorder (ADHD), and social phobia (SP).12 Course and Outcome
SAD can be short-lived or chronic and persistent. Last and colleagues13 followed children in an anxiety clinic prospectively for 3 to 4 years and found that SAD had the highest remission rate (95.7%) of all the anxiety disorders. In another prospective study, young children in a community sample were assessed at age 3 (n 5 60) and 3.5 years later (n 5 44) to evaluate the stability of SAD.14 At baseline, the children were classified as having clinical, subclinical, or nonclinical levels of separation anxiety. Children who met full diagnostic criteria for SAD compared with those with subclinical or nonclinical status were more likely to have comorbid disorders and high levels of internalizing symptoms. In addition, parents of children with clinical SAD experienced high levels of internalizing symptoms and general distress. At follow-up, many children showed a decline in separation anxiety symptoms and moved in the
Anxiety Disorders and PTSD Update
direction of subclinical or nonclinical status. The investigators suggested family and parental characteristics (eg, inconsistency in limit setting) predict lower likelihood of remission of SAD. Foley and colleagues15 assessed the short-term outcome of SAD in a community sample of twins (ages 8 to 17). At an average follow-up period of 18 months, SAD had remitted in 80% of the children. Persistent SAD was predicted by oppositional defiant disorder, impairment because of ADHD, and maternal marital dissatisfaction. Children with persistent SAD were significantly more likely than children with remitted SAD to develop a new depressive disorder within 18 months. SAD is a risk factor for development of anxiety and depressive disorders in adulthood. A controversy exists in the literature as to whether SAD increases the vulnerability for several anxiety disorders or specifically for panic disorder. Data from the Oregon Adolescent Depression Project9 were used to determine the risk that SAD confers for new disorders in adulthood. Teenagers were evaluated at age 16, including retrospective reports of childhood psychopathology. They were assessed twice during adolescence and twice as adults. Most teenagers with a history of SAD developed new disorders as adults. The major outcomes were panic disorder (25%) and depression (75%). Several studies have demonstrated that SAD is a risk factor for a variety of anxiety disorders, not specifically panic disorder.16 In a 7-year follow-up study of children treated for an anxiety disorder, children with SAD compared with children with GAD or SP were more likely to have other anxiety disorders, but not specifically panic disorder.16 The association between SAD and future psychopathology does not indicate causality. While SAD may be causal for later psychiatric disorders, it is also possible that SAD and adult panic disorder and depression are caused by a common underlying vulnerability. ‘‘If the latter is true, then it may also be true that SAD is a marker for severity of the underlying vulnerability.’’9
GENERALIZED ANXIETY DISORDER Clinical Presentation
GAD is a relatively new diagnosis in children and adolescents. In the DSM-III-R17 a diagnosis of GAD required a minimum age of 18 years. Instead, youth with excessive worry were diagnosed with overanxious disorder (OAD). OAD was omitted from the DSM-IV18 and the age restriction was removed from the GAD diagnostic criteria. DSM-IV-TR criteria for GAD are similar for youth when compared with adults, with one exception. The differentiating factor is that youth are only required to endorse one associated symptom (ie, restlessness, fatigue, difficulty concentrating, irritability, muscle aches or tension, or sleep difficulties), and three are required for a diagnosis of GAD in adults (see Table 1). Common domains of worry in children with GAD include health of significant others, personal performance, family matters, and world issues.19 Because the number of associated symptoms differentiates DSM-IV-TR criteria for GAD in children and adults, this domain has been an area of interest. Research has consistently shown that youth diagnosed with GAD typically endorse more than one associated symptom.19,20 Three studies19,21,22 show that restlessness is the most common and muscle tension is the least common associated symptom endorsed by youth with GAD. There are limited data on the prevalence of GAD in youth, as it was not diagnosed in children and adolescents until the DSM-IV. The prevalence rate of OAD in early adolescents was estimated at approximately 3%.23,24 The National Comorbidity Survey, which included individuals ranging in age from 15 to 54 years old, provided GAD prevalence rates from 1.6% current to 5.1% lifetime.25
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GAD is often comorbid with other psychiatric disorders. Masi and colleagues20 found that 93% of clinically referred youth with a diagnosis of GAD (n 5 157) had at least one comorbid disorder. A similar rate of comorbidity of 86% was found in a nonclinical sample of 49 youth diagnosed with GAD.19 There were differences in the pattern of comorbidity between the clinical and nonclinical samples. Depression was diagnosed in 56% of the clinical sample and was the most common comorbid disorder. In contrast, it was only present in 4% of the nonclinical sample and other anxiety disorders were the most common comorbid disorders. Other anxiety disorders were also common in the clinical sample: specific phobia (42%), SAD (31.8%), SP (28%), obsessive-compulsive disorder (OCD) (19.7%), and panic disorder (16.6%). Externalizing disorders (ie, ADHD, oppositional defiant disorder, conduct disorder) occurred in 21% of the clinical sample diagnosed with GAD. Course and Outcome
GAD has a bimodal age of onset with an early onset occurring during childhood and adolescence and a later onset during adulthood.25 Childhood-onset GAD is usually associated with a greater degree of psychopathology and a chronic course with fluctuations in symptom severity.26,27 Children with GAD and a comorbid diagnosis of depression often have a poorer prognosis, greater symptom severity, and longer duration of symptoms when compared with children without comorbid depression.28 Because of high comorbidity rates between GAD and depression, there is speculation as to whether these are two distinct disorders. Researchers have suggested that GAD may be a subsyndrome to major depressive disorder (MDD) because of ‘‘sequential comorbidity,’’ in which GAD typically precedes MDD.29 Other researchers theorize that the disorders have ‘‘cumulative comorbidity,’’ meaning that the disorders tend to occur during a lifetime but not in a simultaneous manner.29 Moffitt and colleagues29 completed a prospective study following 1,037 participants 3 years to 32 years of age. Results showed a strong cumulative comorbidity from 11 to 32 years of age. Forty-eight percent of participants with MDD had a history of an anxiety disorder and 72% of participants with anxiety had a history of MDD. Findings did not provide strong evidence for sequential comorbidity because GAD was diagnosed first in 42% of participants and MDD was diagnosed first in 32% of participants. These results show a strong relationship between GAD and MDD; however, more longitudinal studies are needed to better understand the association. SOCIAL PHOBIA Clinical Presentation
Before the DSM-IV, SP was not diagnosed in children and adolescents. Youth who endorsed anxiety and avoidance of engaging with unfamiliar people were commonly diagnosed with avoidant disorder of childhood or adolescence. This diagnosis was excluded from the DSM-IV; children and adolescents who fear social and performance situations are now diagnosed with SP. Diagnostic criteria for SP in youth are similar to adult criteria, with a few minor clarifications that take into account developmental differences between adults and children (see Table 1). The primary characteristic of SP is the same across all ages. Individuals with SP experience fear regarding social and performance situations because of anxiety that they will act in an embarrassing way. Children with SP often have poor social skills and have difficulty initiating and maintaining interpersonal relationships.30,31 Beidel and colleagues30 found that in a clinical sample of 50 children (7–13 years old) with SP, 75% reported having few or no friends and 50% were not
Anxiety Disorders and PTSD Update
involved in extracurricular activities. SP also seems to have an impact on children’s functioning in the classroom. Muris and Meesters32 found that higher SP symptoms in a nonclinical sample of children (10–12 years old) was associated with poorer general classroom functioning, increased difficulty with peer relationships, and lower selfesteem. Bernstein and colleagues31 examined classroom functioning in a nonclinical sample of children with SP (7–10 years old) based on teacher reports. Results showed that children with greater severity of SP symptoms had poorer social and leadership skills. In addition, there was an association between the severity of SP symptoms and school difficulties: as SP severity increased, attention and learning problems also increased. The rate of lifetime SP in a community sample of adolescents was found to be 1.6%,33 and substantially higher at 14.9% in a clinical sample of children.11 Mean age of onset for social phobia in clinical samples ranges from 11 to 12 years of age11,34 and the rate of SP increases with age.33 Essau and colleagues33 found that the most commonly feared situations in adolescents were performing in front of others, public speaking, and engaging in conversations. The most frequent anxiety endorsed by these adolescents was the fear that something would happen to cause them to be embarrassed. Beidel and colleagues30 found that 60% of children with SP met criteria for another Axis I disorder. Thirty-six percent of the comorbid disorders were other anxiety disorders. The most common comorbid disorders included the following: 10% of children had GAD, ADHD, or specific phobia; 8% had selective mutism; and 6% had an affective disorder. Course and Outcome
A prospective longitudinal study that followed adolescents until 34 years of age showed that a diagnosis of SP during adolescence significantly increases the individual’s risk for later onset depression.35 Approximately 50% of participants with SP met criteria for a depressive disorder during the follow-up period, which placed them at a twofold risk compared with individuals without a diagnosis of SP. Several factors and SP characteristics were found to be associated with an increased risk for subsequent depression. The contributing factors were parental anxiety or major depression, female gender, childhood behavioral inhibition, and having more than two other anxiety disorders. The contributing SP characteristics were increased level of impairment, persistence of symptoms, and greater degree of severity. In addition to the high rate of depressive disorders found in individuals diagnosed with SP, there is also a high rate of comorbidity of SP and substance use disorders.36 Buckner and colleagues37 found that adolescents who were diagnosed with SP were more likely to be diagnosed with alcohol dependence and cannabis dependence during a follow-up period that ended at 30 years of age when compared with adolescents who did not have a diagnosis of SP. Furthermore, the data provide evidence that SP in adolescents seems to be a unique risk factor for the development of subsequent substance dependence disorders. Because of the high comorbidity rates of subsequent depressive and substance dependence disorders, SP places youth at risk for longterm problems across domains of education, social relationships, and employment. OBSESSIVE-COMPULSIVE DISORDER Clinical Presentation
DSM-IV-TR requires either obsessions or compulsions to meet criteria for OCD.7 Obsessions are recurrent intrusive thoughts, images, or impulses that cause
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excessive anxiety or distress. Compulsions are repetitive behaviors or mental acts that the individual feels compelled to perform in response to an obsession. To be diagnosed with OCD, the individual must experience excessive distress, engage in obsessions or compulsions for greater than 1 hour per day, or experience functional impairment related to the OCD. Young children do not necessarily recognize their obsessions and compulsions as senseless or excessive. Prevalence of OCD in children and adolescents ranges from 1% to 4%.38,39 The male-to-female ratio is approximately 3:2 in youth and changes to a slight female predominance in adulthood.40 Common comorbid conditions are tic disorders, other anxiety disorders, ADHD, pervasive developmental disorder, and depression.41 Almost all children and adolescents with OCD have both obsessions and compulsions. One study showed that 93% of children with OCD experience multiple obsessions and 100% engage in multiple compulsions.42 In a series of 70 consecutive cases of early onset OCD, the most common obsessions were concern about dirt or germs, danger to self or family, and symmetry; the most common compulsions were excessive washing, repeating rituals, and checking behaviors.43 Children with OCD present with a variety of obsessions and compulsions. Stewart and colleagues44 used a principal component analysis to identify factors from the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)45 in a sample of 231 children and adolescents with OCD. The CY-BOCS is a semistructured interview that assesses severity of OCD symptoms and includes a checklist of the types of obsessions and compulsions experienced. Four factors were identified as strongly associated with the presentation of pediatric OCD and accounted for 60% of the symptom variance: preoccupation with contamination/cleaning/aggressive/somatic, symmetry/ordering/repeating/checking, sexual/religious themes, and hoarding.44 There is evidence that suggests a similar four-factor structure is applicable across the lifespan.46 A dimensional approach is useful in understanding the heterogeneity in OCD.44 Course and Outcome
There is a bimodal pattern to age of onset in OCD, with one peak in childhood and a second in adulthood. Age of onset for pediatric OCD is typically around 10 years, with a range from 7.5 to 12.5 years.40 In youth, the mean age at identification is 2.5 years after onset of the disorder. This delay may be in part due to the secretive nature of the symptoms in many children. In a meta-analysis of 16 pediatric samples (n 5 521 participants) followed for 1 to 15.6 years, with the average period to follow-up of 5.7 years, a substantial number of children with OCD achieved remission of symptoms.47 In the pooled sample, 59% of participants no longer met criteria for the OCD diagnosis and 40% did not show any evidence of residual OCD symptoms at follow-up. Predictors of persistence of OCD diagnosis included earlier age of onset, longer duration of illness at ascertainment, and a history of inpatient hospitalization.47 Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
A small subgroup of children with OCD or tics has been classified as having pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).48 This subset of children experiences a sudden onset of OCD or motor tics in association with group A streptococcal infections (eg, ‘‘strep throat’’). Diagnostic criteria for PANDAS include: (1) presence of OCD or tics, (2) prepubertal onset, (3) abrupt onset or episodic course of symptom severity, (4) exacerbations associated with streptococcal infections, and (5) exacerbations associated with neurologic
Anxiety Disorders and PTSD Update
abnormalities (eg, hyperactivity, choreiform movements).48 There is an increased rate of comorbid neuropsychiatric symptoms in children with PANDAS, including separation anxiety, impulsivity, hyperactivity, enuresis, and deterioration in handwriting.48,49 Although streptococcal infections are believed to be involved in the etiologic pathway leading to OCD in children with PANDAS, the mechanism is still under investigation. Research suggests that circulating autoimmune antibodies that cross-react with neuronal structures (particularly the basal ganglia) may play a key role in the pathogenesis of PANDAS.50 Case Example
Peter is an 11-year-old boy presenting with a two-year history of intrusive, obsessive thoughts and compulsive, ritualistic behaviors. The obsessions began at around 9 years of age with concern about contamination of food. Peter would not eat anything that a family member had touched. Before preparing food, Peter required that his mother put on a clean outfit and thoroughly wash her hands. If he observed his mother touch the kitchen countertop or cough or sneeze during meal preparation, he demanded that she change clothes and wash her hands again. If she did not comply, Peter would not eat the food she prepared. One of Peter’s prominent intrusive thoughts was that meat was not thoroughly cooked. He asked his mother multiple times whether she had cooked the meat long enough. He worried that that he or a family member might contract mad cow disease and die if the meat was not completely cooked. He refused to eat at restaurants because of his concerns about contamination and whether meat was completely cooked. He did not eat the hot lunch at school and brought his own lunch instead. Peter washed his hands multiple times during the day, using large amounts of soap and spending up to 30 minutes washing at a time. If he was interrupted, he restarted the compulsion that consisted of washing each hand an even number of times. Obsessions and compulsions were causing substantial impairment. Peter was often late to school because of the excessive time he spent engaged in washing and grooming rituals. He walked two blocks to school. On his way to school, he felt compelled to pick up candy and gum wrappers and other paper scraps and stuff them into his pockets. This also contributed to his tardiness. He was having difficulty concentrating on schoolwork and homework because of his obsessive thoughts. After returning home from school, Peter emptied his pockets. He hoarded the paper scraps in his closet and under the bed. Total time spent in obsessions and compulsions was approximately 5 hours per day. He had lost 6 pounds because of his restricted eating. There was no history of psychiatric assessments or interventions for OCD. Initially, Peter was very secretive about his symptoms. Medical history was noncontributory. The OCD symptoms came on gradually and onset and exacerbations were not associated with streptococcal infections. Family psychiatric history was positive for an older brother with OCD and Tourette’s disorder, a paternal aunt with OCD, and Peter’s father, who had obsessive tendencies. Mental status examination revealed a preadolescent boy who was neatly dressed and groomed. He would not shake hands with the examiner. Peter’s hands were noticeably red, dry, and chapped because of frequent handwashing. He opened the door to the examination room using a Kleenex so his hand did not touch the knob and he appeared worried about sitting in the chair, but did so after encouragement from his mother. Mood was described by his mother as ‘‘nervous and irritable’’ and affect was anxious. He was embarrassed to talk about his symptoms. Thought content was remarkable for intrusive thoughts. There were no suicidal or homicidal ideations. There was no evidence of psychosis. No motor tics, vocal tics, or hyperactivity were
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observed. Insight was limited. Peter did not view his obsessions and compulsions as irrational or unreasonable. Peter was diagnosed with OCD with a Global Assessment of Functioning score of 48. Because of the severity of his symptoms, a multimodal approach including cognitive-behavioral therapy (CBT) for OCD and a selective serotonin reuptake inhibitor (SSRI) was recommended. Peter and his parents agreed to participate in CBT, as well as initiate an SSRI. Peter was gradually titrated to a therapeutic dose of the SSRI. In the meantime, he actively participated in weekly CBT sessions that provided him and his parents with skills to manage and reduce his obsessions and compulsions. Peter and his parents were provided with psychoeducation about OCD. Peter then learned and implemented cognitive modification, relaxation skills, and exposure and response prevention to resist his compulsive behaviors and manage his obsessive thoughts. With the combination of an SSRI and CBT, Peter noticed a reduction in the frequency and severity of his obsessions and compulsions. Over time, he was able to eat foods prepared by his mother without requiring her to wash and change her clothes before meal preparation and was able to throw away candy wrappers and other papers that he hoarded under his bed and in the closet. Eventually, Peter stopped picking up trash on the way to school and he spent less time engaged in washing his hands.
POSTTRAUMATIC STRESS DISORDER Clinical Presentation
Clinical presentation of posttraumatic stress disorder (PTSD) in older children and adolescents is similar to that in adults. Older children and adolescents have a better understanding of the traumatic experiences and the long-term consequences than children.51 Additionally, they have the cognitive abilities to describe symptoms of re-experiencing, avoidance, numbing, and dissociation. Carrion and colleagues52 assessed the frequency and intensity of PTSD symptoms in children ranging from 7 to 14 years of age. The most frequent symptoms included: 83% engaged in avoidance of thoughts, feelings, and conversations associated with the trauma; 70% had distressing recollections and the inability to recall important aspects of the traumatic event; and 64% reported problems concentrating. Children rated irritability and anger, distressing dreams, and detachment from others as the most intense symptoms. Clinical presentation of PTSD in young children tends to be markedly different than that in older children, adolescents, and adults. Young children are less likely to demonstrate emotional numbing and avoidance, which is likely because of the complicated cognitive introspection that is required.51 Young children are more likely to exhibit overt aggression, destructive behavior, and repetitive play about the traumatic event. Because of these developmental differences in clinical presentation, it is less likely that young children will meet DSM-IV-TR criteria for PTSD. Alternative criteria that are more developmentally appropriate to diagnose PTSD in infants and younger children have been proposed and are being evaluated.53–55 Many of the adult PTSD symptoms depend on higher-level cognitive functions (ie, memory, abstract thinking, emotional processing, language).54 The criteria being investigated for younger children are less dependent on verbalizations and rely more on behavioral observations. The alternative criteria do not require young children to demonstrate an intense fear response during the traumatic event. The re-experiencing criteria emphasize posttraumatic play and play reenactment of the traumatic event. Young children are not required to exhibit avoidance behaviors related to the traumatic event or beliefs regarding a shortened future and recall of the event is not assessed. Instead,
Anxiety Disorders and PTSD Update
it is proposed that young children demonstrate a numbing of responsiveness through constricted play, socially withdrawn behavior, and restricted range of affect. Young children need to show increased arousal similar to DSM-IV-TR criteria. The proposed criteria include an additional domain, which is related to the development of new fears and aggression (ie, separation anxiety, fear of toileting alone, fear of the dark). The duration of the symptoms is still at least 1 month; however, the symptoms do not need to cause significant distress or impairment. These proposed criteria are not part of the DSM-IV-TR at this time. Prevalence of pediatric PTSD was studied in the Great Smoky Mountains Study (GSMS), which is a longitudinal community study of childhood psychopathology that included 1,420 youths ranging in age from 9 to 16 years. At 16 years of age, 67.8% of participants reported exposure to at least one traumatic event and the trauma occurred more often during adolescence, as compared with childhood.56 Of the participants exposed to trauma, 40.4% met criteria for a psychiatric disorder, compared with 25.5% of participants who were not exposed to trauma. Only 0.5% of the sample met full criteria for PTSD; however, higher rates of subclinical PTSD and painful recall were endorsed. Subclinical PTSD (ie, one symptom of painful recall, hyperarousal, and avoidance) was present in 2.2% of the youth and painful recall was present in 9.1% of the youth. The occurrence of PTSD in a community sample of older adolescents is shown to be higher than reported in the GSMS that included younger children. From a sample of 384 adolescents with an average age of 17.9 years, 43% reported experiencing a traumatic event.57 Of these participants, 14.5% met full DSM-III-R criteria for PTSD (ie, 6.3% of total sample). The median age of onset of PTSD was 16 years. The rate of trauma did not significantly differ between males and females; however, females were six times more likely to meet criteria for PTSD. Adolescents diagnosed with PTSD were seven times more likely to develop another psychiatric disorder (most commonly major depression or substance dependence) compared with adolescents with no trauma exposure and four times more likely compared with other adolescents who experienced trauma but did not meet criteria for PTSD. Course and Outcome
Risk factors associated with the development of PTSD in youth are based on factors before the trauma, related to the trauma, and following the trauma. Parental psychopathology and family conflict significantly increase the risk of youth experiencing a traumatic event.58 Other risk factors related to the youth’s life before the trauma include: history of poor social support and adverse life events, parental poverty, history of childhood maltreatment, poor family functioning, family history of psychiatric disorders, introversion or extreme behavioral inhibition, female gender, younger age, poor health, and history of psychiatric disorder.59,60 Risk factors for PTSD associated with the traumatic experience include the degree of trauma exposure and the parent’s and child’s subjective sense of danger.61 Witnessing a threat to a primary caregiver during infancy, childhood, and adolescence is related to an increase in total number of PTSD symptoms.62 Lack of social support, continued negative life events, parental reactions, and lack of posttrauma intervention are risk factors associated with poor outcome after the trauma.61 SUMMARY
Anxiety disorders are commonly diagnosed in children and adolescents. Prevalence rates range from 2% to 27%, depending on the length of the assessment interval.
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Therefore, it is important to identify and treat pediatric anxiety disorder to reduce the long-term consequences. Although anxiety disorders often have similar clinical presentations in youth and adults, it is critical to understand the differences that may occur across the lifespan. ACKNOWLEDGMENTS
The authors would like to thank Heidi Fall and Bonnie Allen, administrative assistants in the Division of Child and Adolescent Psychiatry, for their help in preparing the manuscript. REFERENCES
1. Costello EJ, Egger HL, Angold A. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Child Adolesc Psychiatr Clin N Am 2005;14(4):631–48, vii. 2. Costello EJ, Angold A, Burns BJ, et al. The great smoky mountains study of youth. Goals, design, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry 1996;53(12):1129–36. 3. Simonoff E, Pickles A, Meyer JM, et al. The Virginia twin study of adolescent behavioral development. Influences of age, sex, and impairment on rates of disorder. Arch Gen Psychiatry 1997;54(9):801–8. 4. Beals J, Piasecki J, Nelson S, et al. Psychiatric disorder among American Indian adolescents: prevalence in northern plains youth. J Am Acad Child Adolesc Psychiatry 1997;36(9):1252–9. 5. Costello EJ, Angold A, Keeler GP. Adolescent outcomes of childhood disorders: the consequences of severity and impairment. J Am Acad Child Adolesc Psychiatry 1999;38(2):121–8. 6. Lewinsohn PM, Gotlib IH, Lewinsohn M, et al. Gender differences in anxiety disorders and anxiety symptoms in adolescents. J Abnorm Psychol 1998; 107(1):109–17. 7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000. 8. Suveg C, Aschenbrand SG, Kendall PC. Separation anxiety disorder, panic disorder, and school refusal. Child Adolesc Psychiatr Clin N Am 2005;14(4):773–95. 9. Lewinsohn PM, Holm-Denoma JM, Small JW, et al. Separation anxiety disorder in childhood as a risk factor for future mental illness. J Am Acad Child Adolesc Psychiatry 2008;47(5):548–55. 10. Shear K, Jin R, Ruscio AM, et al. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National comorbidity survey replication. Am J Psychiatry 2006;163(6):1074–83. 11. Last CG, Perrin S, Hersen M, et al. DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry 1992;31(6):1070–6. 12. Verduin TL, Kendall PC. Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol 2003;32(2):290–5. 13. Last CG, Perrin S, Hersen M, et al. A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 1996;35:1502–10. 14. Kearney CA, Sims KE, Pursell CR, et al. Separation anxiety disorder in young children: a longitudinal and family analysis. J Clin Child Adolesc Psychol 2003;32(4): 593–8.
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15. Foley DL, Pickles A, Maes HM, et al. Course and short-term outcomes of separation anxiety disorder in a community sample of twins. J Am Acad Child Adolesc Psychiatry 2004;43(9):1107–14. 16. Aschenbrand SG, Kendall PC, Webb A, et al. Is childhood separation anxiety disorder a predictor of adult panic disorder and agoraphobia? A seven-year longitudinal study. J Am Acad Child Adolesc Psychiatry 2003;42(12):1478–85. 17. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, third edition. Washington, DC: American Psychiatric Association; 1987. 18. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association; 1994. 19. Layne AE, Bernat DH, Victor AM, et al. Generalized anxiety disorder in a nonclinical sample of children: symptom presentation and predictors of impairment. J Anxiety Disord 2008; 10.1016/j.janxdis.2008.08.003, in press. 20. Masi G, Millepiedi S, Mucci M, et al. Generalized anxiety disorder in referred children and adolescents. J Am Acad Child Adolesc Psychiatry 2004;43(6):752–60. 21. Kendall PC, Pimentel SS. On the physiological symptom constellation in youth with generalized anxiety disorder (GAD). J Anxiety Disord 2003;17(2):211–21. 22. Tracey SA, Chorpita BF, Douban J, et al. Empirical evaluation of DSM-IV generalized anxiety disorder criteria in children and adolescents. J Clin Child Psychol 1997;26(4):404–14. 23. Anderson JC, Williams S, McGee R, et al. DSM-III disorders in preadolescent children. Prevalence in a large sample from the general population. Arch Gen Psychiatry 1987;44(1):69–76. 24. Bowen RC, Offord DR, Boyle MH. The prevalence of overanxious disorder and separation anxiety disorder: results from the Ontario child health study. J Am Acad Child Adolesc Psychiatry 1990;29(5):753–8. 25. Wittchen HU, Zhao S, Kessler RC, et al. DSM-III-R generalized anxiety disorder in the national comorbidity survey. Arch Gen Psychiatry 1994;51(5):355–64. 26. Bell-Dolan DJ, Last CG, Strauss CC. Symptoms of anxiety disorders in normal children. J Am Acad Child Adolesc Psychiatry 1990;29(5):759–65. 27. Hoehn-Saric R, Hazlett RL, McLeod DR. Generalized anxiety disorder with early and late onset of anxiety symptoms. Compr Psychiatry 1993;34(5):291–8. 28. Masi G, Mucci M, Favilla L, et al. Symptomatology and comorbidity of generalized anxiety disorder in children and adolescents. Compr Psychiatry 1999; 40(3):210–5. 29. Moffitt TE, Harrington H, Caspi A, et al. Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 2007;64(6):651–60. 30. Beidel DC, Turner SM, Morris TL. Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry 1999;38(6):643–50. 31. Bernstein GA, Bernat DH, Davis AA, et al. Symptom presentation and classroom functioning in a nonclinical sample of children with social phobia. Depress Anxiety 2008;25(9):752–60. 32. Muris P, Meesters C. Symptoms of anxiety disorders and teacher-reported school functioning of normal children. Psychol Rep 2002;91(2):588–90. 33. Essau CA, Conradt J, Petermann F. Frequency and comorbidity of social phobia and social fears in adolescents. Behav Res Ther 1999;37(9):831–43. 34. Strauss CC, Last CG. Social and simple phobias in children. J Anxiety Disord 1993;7:141–52.
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35. Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007;64(8):903–12. 36. Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety disorder in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2005;66(11):1351–61. 37. Buckner JD, Schmidt NB, Lang AR, et al. Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence. J Psychiatr Res 2008;42(3):230–9. 38. Rapoport JL, Inoff-Germain G, Weissman MM, et al. Childhood obsessive-compulsive disorder in the NIMH MECA study: parent versus child identification of cases. Methods for the epidemiology of child and adolescent mental disorders. J Anxiety Disord 2000;14(6):535–48. 39. Valleni-Basile LA, Garrison CZ, Jackson KL, et al. Frequency of obsessive-compulsive disorder in a community sample of young adolescents. J Am Acad Child Adolesc Psychiatry 1994;33(6):782–91. 40. Geller D, Biederman J, Jones J, et al. Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. J Am Acad Child Adolesc Psychiatry 1998;37(4):420–7. 41. Geller DA. Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatr Clin North Am 2006;29(2):353–70. 42. Geller DA, Biederman J, Faraone S, et al. Developmental aspects of obsessive compulsive disorder: findings in children, adolescents, and adults. J Nerv Ment Dis 2001;189(7):471–7. 43. Swedo SE, Rapoport JL, Leonard H, et al. Obsessive-compulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989;46(4):335–41. 44. Stewart SE, Rosario MC, Brown TA, et al. Principal components analysis of obsessive-compulsive disorder symptoms in children and adolescents. Biol Psychiatry 2007;61(3):285–91. 45. Scahill L, Riddle MA, McSwiggin-Hardin M, et al. Children’s Yale-Brown obsessive compulsive scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 1997;36(6):844–52. 46. Stewart SE, Rosario MC, Baer L, et al. Four-factor structure of obsessive-compulsive disorder symptoms in children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 2008;47(7):763–72. 47. Stewart SE, Geller DA, Jenike M, et al. Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand 2004;110(1):4–13. 48. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry 1998;155(2):264–71. 49. Murphy ML, Pichichero ME. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med 2002;156(4):356–61. 50. Dale RC, Heyman I, Giovannoni G, et al. Incidence of anti-brain antibodies in children with obsessive-compulsive disorder. Br J Psychiatry 2005;187:314–9. 51. Dyregrov A, Yule W. A review of PTSD in children. Child Adolesc Psychiatry Ment Health 2006;11:176–84. 52. Carrion VG, Weems CF, Ray R, et al. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry 2002;41(2):166–73.
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53. Scheeringa MS, Peebles CD, Cook CA, et al. Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. J Am Acad Child Adolesc Psychiatry 2001;40(1):52–60. 54. Scheeringa MS, Zeanah CH, Drell MJ, et al. Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. J Am Acad Child Adolesc Psychiatry 1995;34(2):191–200. 55. Scheeringa MS, Zeanah CH, Myers L, et al. New findings on alternative criteria for PTSD in preschool children. J Am Acad Child Adolesc Psychiatry 2003;42(5): 561–70. 56. Copeland WE, Keeler G, Angold A, et al. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry 2007;64(5):577–84. 57. Giaconia RM, Reinherz HZ, Silverman AB, et al. Traumas and posttraumatic stress disorder in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry 1995;34(10):1369–80. 58. Costello EJ, Erkanli A, Fairbank JA, et al. The prevalence of potentially traumatic events in childhood and adolescence. J Trauma Stress 2002;15(2):99–112. 59. Davidson JRT, Foa EB. Posttraumatic stress disorder: DSM-IV and beyond. Washington, DC: American Psychiatric Press; 1993. 60. Lonigan CJ, Phillips BM, Richey JA. Posttraumatic stress disorder in children: diagnosis, assessment, and associated features. Child Adolesc Psychiatr Clin N Am 2003;12(2):171–94. 61. Pynoos RS, Nader K. Mental health disturbances in children exposed to disaster: prevention intervention strategies. In: Goldston SE, Yager J, Heinicke CM, et al, editors. Preventing Mental Health Disturbances in Childhood. 1st edition. Washington, DC: American Psychiatric Press; 1990. p. 211–33. 62. Scheeringa MS, Wright MJ, Hunt JP, et al. Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. Am J Psychiatry 2006;163(4):644–51.
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Pediatric anxiety disorders Separation anxiety disorder Generalized anxiety disorder Social phobia Obsessive-compulsive disorder Posttraumatic stress disorder
Anxiety disorders are one of the most prevalent categories of pediatric psychopathology.1 There is a range of prevalence estimates based on the type of epidemiologic study that is completed. Short assessment intervals and single collection points result in the lowest prevalence estimates. Childhood prevalence studies of having any anxiety disorder show that 3-month estimates range from 2.2% to 8.6%2,3 and 6-month estimates range from 5.5% to 17.7%.4,5 In contrast, retrospective studies with older adolescents and adults that use a lifetime interval typically report higher prevalence estimates. Lifetime prevalence estimates range from 8.3% to 27%.6 Because pediatric anxiety disorders are relatively common, there is an increasing interest in understanding the research and clinical issues related to the presentation and treatment of these disorders. Anxiety disorders are diagnosed throughout the life span. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)7 criteria are similar for youth and adults; however, there are some notable differences that need to be considered when diagnosing anxiety disorders in children and adolescents. Table 1 provides a summary of the differences in diagnostic criteria for pediatric anxiety disorders. SEPARATION ANXIETY DISORDER Clinical Presentation
The key feature of separation anxiety disorder (SAD) is excessive anxiety about separation from primary attachment figures (eg, parents, grandparents). Children with SAD fear that harm will come to themselves or their attachment figures when separated. Other symptoms include distress at the time of separation, somatic complaints
Division of Child & Adolescent Psychiatry, University of Minnesota Medical School, 2450 Riverside Avenue, F256/2B West, Minneapolis, MN 55454, USA * Corresponding author. E-mail address: [email protected] (A.M. Victor). Psychiatr Clin N Am 32 (2009) 57–69 doi:10.1016/j.psc.2008.11.004 0193-953X/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
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Table 1 DSM-IV-TR criteria differences for anxiety disorders in youth Anxiety Disorder
Differences in Criteria forYouth
Generalized anxiety disorder
Requires only one associated symptom.
Social phobia
Children must have the ability to develop age appropriate friendships Children must endorse anxiety with adults and peers Anxiety may be shown through crying, tantrums, freezing, or shrinking from social situations Children do not need to recognize that the fear is excessive or unreasonable
Obsessive-compulsive disorder
Children do not need to recognize that the obsessions and compulsions are excessive or unreasonable
Posttraumatic stress disorder
Response to the traumatic event may be expressed through agitated or disorganized behavior rather than extreme fear, helplessness, or horror Traumatic event may be re-experienced through the use of repetitive play about the trauma Children may have scary dreams without recognizable content that is related to the event Children may re-enact trauma-specific details
when separation occurs or is anticipated, nightmares with themes of separation, shadowing parents in the home, and sleeping with family members.7 Children with SAD commonly refuse to attend school and are reluctant to go other places without their parents. To be diagnosed with SAD, symptoms must be more intense than expected for the child’s developmental level, be present for at least 4 weeks, have an onset before 18 years of age, and cause significant distress or impairment. A distinguishing feature of SAD is that the child’s anxiety is alleviated when with parents, whereas in other anxiety disorders, the presence of an attachment figure has minimal effect on symptom presentation.8 SAD is common in youth with a prevalence rate of 3% to 5%.9,10 It is more likely to occur in children compared with adolescents. Onset is typically at 7 to 9 years of age.9,11 Common comorbid diagnoses include generalized anxiety disorder (GAD), specific phobia, attention-deficit hyperactivity disorder (ADHD), and social phobia (SP).12 Course and Outcome
SAD can be short-lived or chronic and persistent. Last and colleagues13 followed children in an anxiety clinic prospectively for 3 to 4 years and found that SAD had the highest remission rate (95.7%) of all the anxiety disorders. In another prospective study, young children in a community sample were assessed at age 3 (n 5 60) and 3.5 years later (n 5 44) to evaluate the stability of SAD.14 At baseline, the children were classified as having clinical, subclinical, or nonclinical levels of separation anxiety. Children who met full diagnostic criteria for SAD compared with those with subclinical or nonclinical status were more likely to have comorbid disorders and high levels of internalizing symptoms. In addition, parents of children with clinical SAD experienced high levels of internalizing symptoms and general distress. At follow-up, many children showed a decline in separation anxiety symptoms and moved in the
Anxiety Disorders and PTSD Update
direction of subclinical or nonclinical status. The investigators suggested family and parental characteristics (eg, inconsistency in limit setting) predict lower likelihood of remission of SAD. Foley and colleagues15 assessed the short-term outcome of SAD in a community sample of twins (ages 8 to 17). At an average follow-up period of 18 months, SAD had remitted in 80% of the children. Persistent SAD was predicted by oppositional defiant disorder, impairment because of ADHD, and maternal marital dissatisfaction. Children with persistent SAD were significantly more likely than children with remitted SAD to develop a new depressive disorder within 18 months. SAD is a risk factor for development of anxiety and depressive disorders in adulthood. A controversy exists in the literature as to whether SAD increases the vulnerability for several anxiety disorders or specifically for panic disorder. Data from the Oregon Adolescent Depression Project9 were used to determine the risk that SAD confers for new disorders in adulthood. Teenagers were evaluated at age 16, including retrospective reports of childhood psychopathology. They were assessed twice during adolescence and twice as adults. Most teenagers with a history of SAD developed new disorders as adults. The major outcomes were panic disorder (25%) and depression (75%). Several studies have demonstrated that SAD is a risk factor for a variety of anxiety disorders, not specifically panic disorder.16 In a 7-year follow-up study of children treated for an anxiety disorder, children with SAD compared with children with GAD or SP were more likely to have other anxiety disorders, but not specifically panic disorder.16 The association between SAD and future psychopathology does not indicate causality. While SAD may be causal for later psychiatric disorders, it is also possible that SAD and adult panic disorder and depression are caused by a common underlying vulnerability. ‘‘If the latter is true, then it may also be true that SAD is a marker for severity of the underlying vulnerability.’’9
GENERALIZED ANXIETY DISORDER Clinical Presentation
GAD is a relatively new diagnosis in children and adolescents. In the DSM-III-R17 a diagnosis of GAD required a minimum age of 18 years. Instead, youth with excessive worry were diagnosed with overanxious disorder (OAD). OAD was omitted from the DSM-IV18 and the age restriction was removed from the GAD diagnostic criteria. DSM-IV-TR criteria for GAD are similar for youth when compared with adults, with one exception. The differentiating factor is that youth are only required to endorse one associated symptom (ie, restlessness, fatigue, difficulty concentrating, irritability, muscle aches or tension, or sleep difficulties), and three are required for a diagnosis of GAD in adults (see Table 1). Common domains of worry in children with GAD include health of significant others, personal performance, family matters, and world issues.19 Because the number of associated symptoms differentiates DSM-IV-TR criteria for GAD in children and adults, this domain has been an area of interest. Research has consistently shown that youth diagnosed with GAD typically endorse more than one associated symptom.19,20 Three studies19,21,22 show that restlessness is the most common and muscle tension is the least common associated symptom endorsed by youth with GAD. There are limited data on the prevalence of GAD in youth, as it was not diagnosed in children and adolescents until the DSM-IV. The prevalence rate of OAD in early adolescents was estimated at approximately 3%.23,24 The National Comorbidity Survey, which included individuals ranging in age from 15 to 54 years old, provided GAD prevalence rates from 1.6% current to 5.1% lifetime.25
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GAD is often comorbid with other psychiatric disorders. Masi and colleagues20 found that 93% of clinically referred youth with a diagnosis of GAD (n 5 157) had at least one comorbid disorder. A similar rate of comorbidity of 86% was found in a nonclinical sample of 49 youth diagnosed with GAD.19 There were differences in the pattern of comorbidity between the clinical and nonclinical samples. Depression was diagnosed in 56% of the clinical sample and was the most common comorbid disorder. In contrast, it was only present in 4% of the nonclinical sample and other anxiety disorders were the most common comorbid disorders. Other anxiety disorders were also common in the clinical sample: specific phobia (42%), SAD (31.8%), SP (28%), obsessive-compulsive disorder (OCD) (19.7%), and panic disorder (16.6%). Externalizing disorders (ie, ADHD, oppositional defiant disorder, conduct disorder) occurred in 21% of the clinical sample diagnosed with GAD. Course and Outcome
GAD has a bimodal age of onset with an early onset occurring during childhood and adolescence and a later onset during adulthood.25 Childhood-onset GAD is usually associated with a greater degree of psychopathology and a chronic course with fluctuations in symptom severity.26,27 Children with GAD and a comorbid diagnosis of depression often have a poorer prognosis, greater symptom severity, and longer duration of symptoms when compared with children without comorbid depression.28 Because of high comorbidity rates between GAD and depression, there is speculation as to whether these are two distinct disorders. Researchers have suggested that GAD may be a subsyndrome to major depressive disorder (MDD) because of ‘‘sequential comorbidity,’’ in which GAD typically precedes MDD.29 Other researchers theorize that the disorders have ‘‘cumulative comorbidity,’’ meaning that the disorders tend to occur during a lifetime but not in a simultaneous manner.29 Moffitt and colleagues29 completed a prospective study following 1,037 participants 3 years to 32 years of age. Results showed a strong cumulative comorbidity from 11 to 32 years of age. Forty-eight percent of participants with MDD had a history of an anxiety disorder and 72% of participants with anxiety had a history of MDD. Findings did not provide strong evidence for sequential comorbidity because GAD was diagnosed first in 42% of participants and MDD was diagnosed first in 32% of participants. These results show a strong relationship between GAD and MDD; however, more longitudinal studies are needed to better understand the association. SOCIAL PHOBIA Clinical Presentation
Before the DSM-IV, SP was not diagnosed in children and adolescents. Youth who endorsed anxiety and avoidance of engaging with unfamiliar people were commonly diagnosed with avoidant disorder of childhood or adolescence. This diagnosis was excluded from the DSM-IV; children and adolescents who fear social and performance situations are now diagnosed with SP. Diagnostic criteria for SP in youth are similar to adult criteria, with a few minor clarifications that take into account developmental differences between adults and children (see Table 1). The primary characteristic of SP is the same across all ages. Individuals with SP experience fear regarding social and performance situations because of anxiety that they will act in an embarrassing way. Children with SP often have poor social skills and have difficulty initiating and maintaining interpersonal relationships.30,31 Beidel and colleagues30 found that in a clinical sample of 50 children (7–13 years old) with SP, 75% reported having few or no friends and 50% were not
Anxiety Disorders and PTSD Update
involved in extracurricular activities. SP also seems to have an impact on children’s functioning in the classroom. Muris and Meesters32 found that higher SP symptoms in a nonclinical sample of children (10–12 years old) was associated with poorer general classroom functioning, increased difficulty with peer relationships, and lower selfesteem. Bernstein and colleagues31 examined classroom functioning in a nonclinical sample of children with SP (7–10 years old) based on teacher reports. Results showed that children with greater severity of SP symptoms had poorer social and leadership skills. In addition, there was an association between the severity of SP symptoms and school difficulties: as SP severity increased, attention and learning problems also increased. The rate of lifetime SP in a community sample of adolescents was found to be 1.6%,33 and substantially higher at 14.9% in a clinical sample of children.11 Mean age of onset for social phobia in clinical samples ranges from 11 to 12 years of age11,34 and the rate of SP increases with age.33 Essau and colleagues33 found that the most commonly feared situations in adolescents were performing in front of others, public speaking, and engaging in conversations. The most frequent anxiety endorsed by these adolescents was the fear that something would happen to cause them to be embarrassed. Beidel and colleagues30 found that 60% of children with SP met criteria for another Axis I disorder. Thirty-six percent of the comorbid disorders were other anxiety disorders. The most common comorbid disorders included the following: 10% of children had GAD, ADHD, or specific phobia; 8% had selective mutism; and 6% had an affective disorder. Course and Outcome
A prospective longitudinal study that followed adolescents until 34 years of age showed that a diagnosis of SP during adolescence significantly increases the individual’s risk for later onset depression.35 Approximately 50% of participants with SP met criteria for a depressive disorder during the follow-up period, which placed them at a twofold risk compared with individuals without a diagnosis of SP. Several factors and SP characteristics were found to be associated with an increased risk for subsequent depression. The contributing factors were parental anxiety or major depression, female gender, childhood behavioral inhibition, and having more than two other anxiety disorders. The contributing SP characteristics were increased level of impairment, persistence of symptoms, and greater degree of severity. In addition to the high rate of depressive disorders found in individuals diagnosed with SP, there is also a high rate of comorbidity of SP and substance use disorders.36 Buckner and colleagues37 found that adolescents who were diagnosed with SP were more likely to be diagnosed with alcohol dependence and cannabis dependence during a follow-up period that ended at 30 years of age when compared with adolescents who did not have a diagnosis of SP. Furthermore, the data provide evidence that SP in adolescents seems to be a unique risk factor for the development of subsequent substance dependence disorders. Because of the high comorbidity rates of subsequent depressive and substance dependence disorders, SP places youth at risk for longterm problems across domains of education, social relationships, and employment. OBSESSIVE-COMPULSIVE DISORDER Clinical Presentation
DSM-IV-TR requires either obsessions or compulsions to meet criteria for OCD.7 Obsessions are recurrent intrusive thoughts, images, or impulses that cause
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excessive anxiety or distress. Compulsions are repetitive behaviors or mental acts that the individual feels compelled to perform in response to an obsession. To be diagnosed with OCD, the individual must experience excessive distress, engage in obsessions or compulsions for greater than 1 hour per day, or experience functional impairment related to the OCD. Young children do not necessarily recognize their obsessions and compulsions as senseless or excessive. Prevalence of OCD in children and adolescents ranges from 1% to 4%.38,39 The male-to-female ratio is approximately 3:2 in youth and changes to a slight female predominance in adulthood.40 Common comorbid conditions are tic disorders, other anxiety disorders, ADHD, pervasive developmental disorder, and depression.41 Almost all children and adolescents with OCD have both obsessions and compulsions. One study showed that 93% of children with OCD experience multiple obsessions and 100% engage in multiple compulsions.42 In a series of 70 consecutive cases of early onset OCD, the most common obsessions were concern about dirt or germs, danger to self or family, and symmetry; the most common compulsions were excessive washing, repeating rituals, and checking behaviors.43 Children with OCD present with a variety of obsessions and compulsions. Stewart and colleagues44 used a principal component analysis to identify factors from the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)45 in a sample of 231 children and adolescents with OCD. The CY-BOCS is a semistructured interview that assesses severity of OCD symptoms and includes a checklist of the types of obsessions and compulsions experienced. Four factors were identified as strongly associated with the presentation of pediatric OCD and accounted for 60% of the symptom variance: preoccupation with contamination/cleaning/aggressive/somatic, symmetry/ordering/repeating/checking, sexual/religious themes, and hoarding.44 There is evidence that suggests a similar four-factor structure is applicable across the lifespan.46 A dimensional approach is useful in understanding the heterogeneity in OCD.44 Course and Outcome
There is a bimodal pattern to age of onset in OCD, with one peak in childhood and a second in adulthood. Age of onset for pediatric OCD is typically around 10 years, with a range from 7.5 to 12.5 years.40 In youth, the mean age at identification is 2.5 years after onset of the disorder. This delay may be in part due to the secretive nature of the symptoms in many children. In a meta-analysis of 16 pediatric samples (n 5 521 participants) followed for 1 to 15.6 years, with the average period to follow-up of 5.7 years, a substantial number of children with OCD achieved remission of symptoms.47 In the pooled sample, 59% of participants no longer met criteria for the OCD diagnosis and 40% did not show any evidence of residual OCD symptoms at follow-up. Predictors of persistence of OCD diagnosis included earlier age of onset, longer duration of illness at ascertainment, and a history of inpatient hospitalization.47 Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
A small subgroup of children with OCD or tics has been classified as having pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).48 This subset of children experiences a sudden onset of OCD or motor tics in association with group A streptococcal infections (eg, ‘‘strep throat’’). Diagnostic criteria for PANDAS include: (1) presence of OCD or tics, (2) prepubertal onset, (3) abrupt onset or episodic course of symptom severity, (4) exacerbations associated with streptococcal infections, and (5) exacerbations associated with neurologic
Anxiety Disorders and PTSD Update
abnormalities (eg, hyperactivity, choreiform movements).48 There is an increased rate of comorbid neuropsychiatric symptoms in children with PANDAS, including separation anxiety, impulsivity, hyperactivity, enuresis, and deterioration in handwriting.48,49 Although streptococcal infections are believed to be involved in the etiologic pathway leading to OCD in children with PANDAS, the mechanism is still under investigation. Research suggests that circulating autoimmune antibodies that cross-react with neuronal structures (particularly the basal ganglia) may play a key role in the pathogenesis of PANDAS.50 Case Example
Peter is an 11-year-old boy presenting with a two-year history of intrusive, obsessive thoughts and compulsive, ritualistic behaviors. The obsessions began at around 9 years of age with concern about contamination of food. Peter would not eat anything that a family member had touched. Before preparing food, Peter required that his mother put on a clean outfit and thoroughly wash her hands. If he observed his mother touch the kitchen countertop or cough or sneeze during meal preparation, he demanded that she change clothes and wash her hands again. If she did not comply, Peter would not eat the food she prepared. One of Peter’s prominent intrusive thoughts was that meat was not thoroughly cooked. He asked his mother multiple times whether she had cooked the meat long enough. He worried that that he or a family member might contract mad cow disease and die if the meat was not completely cooked. He refused to eat at restaurants because of his concerns about contamination and whether meat was completely cooked. He did not eat the hot lunch at school and brought his own lunch instead. Peter washed his hands multiple times during the day, using large amounts of soap and spending up to 30 minutes washing at a time. If he was interrupted, he restarted the compulsion that consisted of washing each hand an even number of times. Obsessions and compulsions were causing substantial impairment. Peter was often late to school because of the excessive time he spent engaged in washing and grooming rituals. He walked two blocks to school. On his way to school, he felt compelled to pick up candy and gum wrappers and other paper scraps and stuff them into his pockets. This also contributed to his tardiness. He was having difficulty concentrating on schoolwork and homework because of his obsessive thoughts. After returning home from school, Peter emptied his pockets. He hoarded the paper scraps in his closet and under the bed. Total time spent in obsessions and compulsions was approximately 5 hours per day. He had lost 6 pounds because of his restricted eating. There was no history of psychiatric assessments or interventions for OCD. Initially, Peter was very secretive about his symptoms. Medical history was noncontributory. The OCD symptoms came on gradually and onset and exacerbations were not associated with streptococcal infections. Family psychiatric history was positive for an older brother with OCD and Tourette’s disorder, a paternal aunt with OCD, and Peter’s father, who had obsessive tendencies. Mental status examination revealed a preadolescent boy who was neatly dressed and groomed. He would not shake hands with the examiner. Peter’s hands were noticeably red, dry, and chapped because of frequent handwashing. He opened the door to the examination room using a Kleenex so his hand did not touch the knob and he appeared worried about sitting in the chair, but did so after encouragement from his mother. Mood was described by his mother as ‘‘nervous and irritable’’ and affect was anxious. He was embarrassed to talk about his symptoms. Thought content was remarkable for intrusive thoughts. There were no suicidal or homicidal ideations. There was no evidence of psychosis. No motor tics, vocal tics, or hyperactivity were
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observed. Insight was limited. Peter did not view his obsessions and compulsions as irrational or unreasonable. Peter was diagnosed with OCD with a Global Assessment of Functioning score of 48. Because of the severity of his symptoms, a multimodal approach including cognitive-behavioral therapy (CBT) for OCD and a selective serotonin reuptake inhibitor (SSRI) was recommended. Peter and his parents agreed to participate in CBT, as well as initiate an SSRI. Peter was gradually titrated to a therapeutic dose of the SSRI. In the meantime, he actively participated in weekly CBT sessions that provided him and his parents with skills to manage and reduce his obsessions and compulsions. Peter and his parents were provided with psychoeducation about OCD. Peter then learned and implemented cognitive modification, relaxation skills, and exposure and response prevention to resist his compulsive behaviors and manage his obsessive thoughts. With the combination of an SSRI and CBT, Peter noticed a reduction in the frequency and severity of his obsessions and compulsions. Over time, he was able to eat foods prepared by his mother without requiring her to wash and change her clothes before meal preparation and was able to throw away candy wrappers and other papers that he hoarded under his bed and in the closet. Eventually, Peter stopped picking up trash on the way to school and he spent less time engaged in washing his hands.
POSTTRAUMATIC STRESS DISORDER Clinical Presentation
Clinical presentation of posttraumatic stress disorder (PTSD) in older children and adolescents is similar to that in adults. Older children and adolescents have a better understanding of the traumatic experiences and the long-term consequences than children.51 Additionally, they have the cognitive abilities to describe symptoms of re-experiencing, avoidance, numbing, and dissociation. Carrion and colleagues52 assessed the frequency and intensity of PTSD symptoms in children ranging from 7 to 14 years of age. The most frequent symptoms included: 83% engaged in avoidance of thoughts, feelings, and conversations associated with the trauma; 70% had distressing recollections and the inability to recall important aspects of the traumatic event; and 64% reported problems concentrating. Children rated irritability and anger, distressing dreams, and detachment from others as the most intense symptoms. Clinical presentation of PTSD in young children tends to be markedly different than that in older children, adolescents, and adults. Young children are less likely to demonstrate emotional numbing and avoidance, which is likely because of the complicated cognitive introspection that is required.51 Young children are more likely to exhibit overt aggression, destructive behavior, and repetitive play about the traumatic event. Because of these developmental differences in clinical presentation, it is less likely that young children will meet DSM-IV-TR criteria for PTSD. Alternative criteria that are more developmentally appropriate to diagnose PTSD in infants and younger children have been proposed and are being evaluated.53–55 Many of the adult PTSD symptoms depend on higher-level cognitive functions (ie, memory, abstract thinking, emotional processing, language).54 The criteria being investigated for younger children are less dependent on verbalizations and rely more on behavioral observations. The alternative criteria do not require young children to demonstrate an intense fear response during the traumatic event. The re-experiencing criteria emphasize posttraumatic play and play reenactment of the traumatic event. Young children are not required to exhibit avoidance behaviors related to the traumatic event or beliefs regarding a shortened future and recall of the event is not assessed. Instead,
Anxiety Disorders and PTSD Update
it is proposed that young children demonstrate a numbing of responsiveness through constricted play, socially withdrawn behavior, and restricted range of affect. Young children need to show increased arousal similar to DSM-IV-TR criteria. The proposed criteria include an additional domain, which is related to the development of new fears and aggression (ie, separation anxiety, fear of toileting alone, fear of the dark). The duration of the symptoms is still at least 1 month; however, the symptoms do not need to cause significant distress or impairment. These proposed criteria are not part of the DSM-IV-TR at this time. Prevalence of pediatric PTSD was studied in the Great Smoky Mountains Study (GSMS), which is a longitudinal community study of childhood psychopathology that included 1,420 youths ranging in age from 9 to 16 years. At 16 years of age, 67.8% of participants reported exposure to at least one traumatic event and the trauma occurred more often during adolescence, as compared with childhood.56 Of the participants exposed to trauma, 40.4% met criteria for a psychiatric disorder, compared with 25.5% of participants who were not exposed to trauma. Only 0.5% of the sample met full criteria for PTSD; however, higher rates of subclinical PTSD and painful recall were endorsed. Subclinical PTSD (ie, one symptom of painful recall, hyperarousal, and avoidance) was present in 2.2% of the youth and painful recall was present in 9.1% of the youth. The occurrence of PTSD in a community sample of older adolescents is shown to be higher than reported in the GSMS that included younger children. From a sample of 384 adolescents with an average age of 17.9 years, 43% reported experiencing a traumatic event.57 Of these participants, 14.5% met full DSM-III-R criteria for PTSD (ie, 6.3% of total sample). The median age of onset of PTSD was 16 years. The rate of trauma did not significantly differ between males and females; however, females were six times more likely to meet criteria for PTSD. Adolescents diagnosed with PTSD were seven times more likely to develop another psychiatric disorder (most commonly major depression or substance dependence) compared with adolescents with no trauma exposure and four times more likely compared with other adolescents who experienced trauma but did not meet criteria for PTSD. Course and Outcome
Risk factors associated with the development of PTSD in youth are based on factors before the trauma, related to the trauma, and following the trauma. Parental psychopathology and family conflict significantly increase the risk of youth experiencing a traumatic event.58 Other risk factors related to the youth’s life before the trauma include: history of poor social support and adverse life events, parental poverty, history of childhood maltreatment, poor family functioning, family history of psychiatric disorders, introversion or extreme behavioral inhibition, female gender, younger age, poor health, and history of psychiatric disorder.59,60 Risk factors for PTSD associated with the traumatic experience include the degree of trauma exposure and the parent’s and child’s subjective sense of danger.61 Witnessing a threat to a primary caregiver during infancy, childhood, and adolescence is related to an increase in total number of PTSD symptoms.62 Lack of social support, continued negative life events, parental reactions, and lack of posttrauma intervention are risk factors associated with poor outcome after the trauma.61 SUMMARY
Anxiety disorders are commonly diagnosed in children and adolescents. Prevalence rates range from 2% to 27%, depending on the length of the assessment interval.
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Therefore, it is important to identify and treat pediatric anxiety disorder to reduce the long-term consequences. Although anxiety disorders often have similar clinical presentations in youth and adults, it is critical to understand the differences that may occur across the lifespan. ACKNOWLEDGMENTS
The authors would like to thank Heidi Fall and Bonnie Allen, administrative assistants in the Division of Child and Adolescent Psychiatry, for their help in preparing the manuscript. REFERENCES
1. Costello EJ, Egger HL, Angold A. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Child Adolesc Psychiatr Clin N Am 2005;14(4):631–48, vii. 2. Costello EJ, Angold A, Burns BJ, et al. The great smoky mountains study of youth. Goals, design, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry 1996;53(12):1129–36. 3. Simonoff E, Pickles A, Meyer JM, et al. The Virginia twin study of adolescent behavioral development. Influences of age, sex, and impairment on rates of disorder. Arch Gen Psychiatry 1997;54(9):801–8. 4. Beals J, Piasecki J, Nelson S, et al. Psychiatric disorder among American Indian adolescents: prevalence in northern plains youth. J Am Acad Child Adolesc Psychiatry 1997;36(9):1252–9. 5. Costello EJ, Angold A, Keeler GP. Adolescent outcomes of childhood disorders: the consequences of severity and impairment. J Am Acad Child Adolesc Psychiatry 1999;38(2):121–8. 6. Lewinsohn PM, Gotlib IH, Lewinsohn M, et al. Gender differences in anxiety disorders and anxiety symptoms in adolescents. J Abnorm Psychol 1998; 107(1):109–17. 7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000. 8. Suveg C, Aschenbrand SG, Kendall PC. Separation anxiety disorder, panic disorder, and school refusal. Child Adolesc Psychiatr Clin N Am 2005;14(4):773–95. 9. Lewinsohn PM, Holm-Denoma JM, Small JW, et al. Separation anxiety disorder in childhood as a risk factor for future mental illness. J Am Acad Child Adolesc Psychiatry 2008;47(5):548–55. 10. Shear K, Jin R, Ruscio AM, et al. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National comorbidity survey replication. Am J Psychiatry 2006;163(6):1074–83. 11. Last CG, Perrin S, Hersen M, et al. DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry 1992;31(6):1070–6. 12. Verduin TL, Kendall PC. Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol 2003;32(2):290–5. 13. Last CG, Perrin S, Hersen M, et al. A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 1996;35:1502–10. 14. Kearney CA, Sims KE, Pursell CR, et al. Separation anxiety disorder in young children: a longitudinal and family analysis. J Clin Child Adolesc Psychol 2003;32(4): 593–8.
Anxiety Disorders and PTSD Update
15. Foley DL, Pickles A, Maes HM, et al. Course and short-term outcomes of separation anxiety disorder in a community sample of twins. J Am Acad Child Adolesc Psychiatry 2004;43(9):1107–14. 16. Aschenbrand SG, Kendall PC, Webb A, et al. Is childhood separation anxiety disorder a predictor of adult panic disorder and agoraphobia? A seven-year longitudinal study. J Am Acad Child Adolesc Psychiatry 2003;42(12):1478–85. 17. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, third edition. Washington, DC: American Psychiatric Association; 1987. 18. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association; 1994. 19. Layne AE, Bernat DH, Victor AM, et al. Generalized anxiety disorder in a nonclinical sample of children: symptom presentation and predictors of impairment. J Anxiety Disord 2008; 10.1016/j.janxdis.2008.08.003, in press. 20. Masi G, Millepiedi S, Mucci M, et al. Generalized anxiety disorder in referred children and adolescents. J Am Acad Child Adolesc Psychiatry 2004;43(6):752–60. 21. Kendall PC, Pimentel SS. On the physiological symptom constellation in youth with generalized anxiety disorder (GAD). J Anxiety Disord 2003;17(2):211–21. 22. Tracey SA, Chorpita BF, Douban J, et al. Empirical evaluation of DSM-IV generalized anxiety disorder criteria in children and adolescents. J Clin Child Psychol 1997;26(4):404–14. 23. Anderson JC, Williams S, McGee R, et al. DSM-III disorders in preadolescent children. Prevalence in a large sample from the general population. Arch Gen Psychiatry 1987;44(1):69–76. 24. Bowen RC, Offord DR, Boyle MH. The prevalence of overanxious disorder and separation anxiety disorder: results from the Ontario child health study. J Am Acad Child Adolesc Psychiatry 1990;29(5):753–8. 25. Wittchen HU, Zhao S, Kessler RC, et al. DSM-III-R generalized anxiety disorder in the national comorbidity survey. Arch Gen Psychiatry 1994;51(5):355–64. 26. Bell-Dolan DJ, Last CG, Strauss CC. Symptoms of anxiety disorders in normal children. J Am Acad Child Adolesc Psychiatry 1990;29(5):759–65. 27. Hoehn-Saric R, Hazlett RL, McLeod DR. Generalized anxiety disorder with early and late onset of anxiety symptoms. Compr Psychiatry 1993;34(5):291–8. 28. Masi G, Mucci M, Favilla L, et al. Symptomatology and comorbidity of generalized anxiety disorder in children and adolescents. Compr Psychiatry 1999; 40(3):210–5. 29. Moffitt TE, Harrington H, Caspi A, et al. Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 2007;64(6):651–60. 30. Beidel DC, Turner SM, Morris TL. Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry 1999;38(6):643–50. 31. Bernstein GA, Bernat DH, Davis AA, et al. Symptom presentation and classroom functioning in a nonclinical sample of children with social phobia. Depress Anxiety 2008;25(9):752–60. 32. Muris P, Meesters C. Symptoms of anxiety disorders and teacher-reported school functioning of normal children. Psychol Rep 2002;91(2):588–90. 33. Essau CA, Conradt J, Petermann F. Frequency and comorbidity of social phobia and social fears in adolescents. Behav Res Ther 1999;37(9):831–43. 34. Strauss CC, Last CG. Social and simple phobias in children. J Anxiety Disord 1993;7:141–52.
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Victor & Bernstein
35. Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007;64(8):903–12. 36. Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety disorder in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2005;66(11):1351–61. 37. Buckner JD, Schmidt NB, Lang AR, et al. Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence. J Psychiatr Res 2008;42(3):230–9. 38. Rapoport JL, Inoff-Germain G, Weissman MM, et al. Childhood obsessive-compulsive disorder in the NIMH MECA study: parent versus child identification of cases. Methods for the epidemiology of child and adolescent mental disorders. J Anxiety Disord 2000;14(6):535–48. 39. Valleni-Basile LA, Garrison CZ, Jackson KL, et al. Frequency of obsessive-compulsive disorder in a community sample of young adolescents. J Am Acad Child Adolesc Psychiatry 1994;33(6):782–91. 40. Geller D, Biederman J, Jones J, et al. Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. J Am Acad Child Adolesc Psychiatry 1998;37(4):420–7. 41. Geller DA. Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatr Clin North Am 2006;29(2):353–70. 42. Geller DA, Biederman J, Faraone S, et al. Developmental aspects of obsessive compulsive disorder: findings in children, adolescents, and adults. J Nerv Ment Dis 2001;189(7):471–7. 43. Swedo SE, Rapoport JL, Leonard H, et al. Obsessive-compulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989;46(4):335–41. 44. Stewart SE, Rosario MC, Brown TA, et al. Principal components analysis of obsessive-compulsive disorder symptoms in children and adolescents. Biol Psychiatry 2007;61(3):285–91. 45. Scahill L, Riddle MA, McSwiggin-Hardin M, et al. Children’s Yale-Brown obsessive compulsive scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 1997;36(6):844–52. 46. Stewart SE, Rosario MC, Baer L, et al. Four-factor structure of obsessive-compulsive disorder symptoms in children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 2008;47(7):763–72. 47. Stewart SE, Geller DA, Jenike M, et al. Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand 2004;110(1):4–13. 48. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry 1998;155(2):264–71. 49. Murphy ML, Pichichero ME. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med 2002;156(4):356–61. 50. Dale RC, Heyman I, Giovannoni G, et al. Incidence of anti-brain antibodies in children with obsessive-compulsive disorder. Br J Psychiatry 2005;187:314–9. 51. Dyregrov A, Yule W. A review of PTSD in children. Child Adolesc Psychiatry Ment Health 2006;11:176–84. 52. Carrion VG, Weems CF, Ray R, et al. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry 2002;41(2):166–73.
Anxiety Disorders and PTSD Update
53. Scheeringa MS, Peebles CD, Cook CA, et al. Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. J Am Acad Child Adolesc Psychiatry 2001;40(1):52–60. 54. Scheeringa MS, Zeanah CH, Drell MJ, et al. Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. J Am Acad Child Adolesc Psychiatry 1995;34(2):191–200. 55. Scheeringa MS, Zeanah CH, Myers L, et al. New findings on alternative criteria for PTSD in preschool children. J Am Acad Child Adolesc Psychiatry 2003;42(5): 561–70. 56. Copeland WE, Keeler G, Angold A, et al. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry 2007;64(5):577–84. 57. Giaconia RM, Reinherz HZ, Silverman AB, et al. Traumas and posttraumatic stress disorder in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry 1995;34(10):1369–80. 58. Costello EJ, Erkanli A, Fairbank JA, et al. The prevalence of potentially traumatic events in childhood and adolescence. J Trauma Stress 2002;15(2):99–112. 59. Davidson JRT, Foa EB. Posttraumatic stress disorder: DSM-IV and beyond. Washington, DC: American Psychiatric Press; 1993. 60. Lonigan CJ, Phillips BM, Richey JA. Posttraumatic stress disorder in children: diagnosis, assessment, and associated features. Child Adolesc Psychiatr Clin N Am 2003;12(2):171–94. 61. Pynoos RS, Nader K. Mental health disturbances in children exposed to disaster: prevention intervention strategies. In: Goldston SE, Yager J, Heinicke CM, et al, editors. Preventing Mental Health Disturbances in Childhood. 1st edition. Washington, DC: American Psychiatric Press; 1990. p. 211–33. 62. Scheeringa MS, Wright MJ, Hunt JP, et al. Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. Am J Psychiatry 2006;163(4):644–51.
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