++
Fears and anxiety are manifested in various ways. Some
children may appear visibly nervous. Others may hide their feelings, freeze
in a situation, or express their anxiety as anger or frustration.
While many children experience anxieties and worries at some point
in their lifetime, most do not have clinical disorder. Normative
and problematic anxiety can be distinguished in various ways (see eTable 88.1); ultimately, however, it is often the
degree of interference and distress that determines whether a child
has a clinical anxiety disorder. Specific types of anxiety disorders
are distinguished by hallmark features (see Table
88-1).
++
Anxiety disorders can be described with reference to 3 realms:
physiological, behavioral, and cognitive. Physiological reactions to
feared stimuli include increased heart rate, respiratory rate, blood
pressure, sweating, flushing, nausea, diarrhea, tingling sensations, abdominal
problems, dry mouth, lightheadedness, dizziness, muscle tension,
tremors, and chest pain. Behavioral signs of anxiety typically include
avoidance, social withdrawal, irritability, angry outbursts, crying, clinginess,
insomnia, nightmares, distractibility, hypervigilance, and cautiousness.
Cognitively, children with anxiety often have an attentional bias
toward threat-related information with a tendency to fear the worst
and exaggerate risks.
+++
Continua of
Anxiety: from Fears and Worries to Anxiety Disorders
+++
Clinginess to
Separation Anxiety Disorder
++
Many children feel anxious when separated from their parents
or other caregivers. Separation anxiety is most common between 1
and 3 years of age and mostly resolved by age 5. Thereafter, separation
anxieties would be expected only occasionally, such as when starting
a new school year or going away to camp; typically, however, these
fears are very temporary, usually lasting 2 to 3 days for most children
and 2 to 3 weeks for others. Children with separation anxiety disorder
worry about being away from their parents during school, at bedtime,
or even when their parents are in a different room. Often, they
worry that something bad will happen to them or to their parents
while they are separated. Impairment may include numerous missed
opportunities (eg, camp, sleepovers, social activities), school avoidance,
and sleep problems. As a rule of thumb, if separation fears persist
longer than 1 month without any signs of improvement and are severe
enough to cause some type of impairment, then a clinical disorder
might be suspected.
+++
Shyness to Social
Anxiety Disorder
++
Shyness is a common childhood trait and should not be considered
a clinical disorder unless it is persistent, excessive, and causes some
type of impairment. Behavioral inhibition,1,2 a
temperamental characteristic similar to shyness, is a stable trait
in approximately one third of infants. Children with an inhibited temperament
have been found to be timid with novel or unfamiliar people, objects,
and situations, while uninhibited children spontaneously approach
these stimuli. These behavioral differences are accompanied by physiological
differences, including increased heart rate and heart rate variability, pupillary dilation during cognitive
tasks, vocal cord tension when speaking under moderate stress, and
salivary cortisol levels among the behaviorally inhibited children.
When behavioral inhibition is persistent and stable, a child is
at increased risk for anxiety disorders, specifically social anxiety
disorder.3
++
The hallmark feature of social anxiety disorder is the excessive
concern about negative evaluation and embarrassment in front of others.
This persistent fear is accompanied by increased physiologic arousal
and avoidance of social situations like parties, meeting new children,
starting a conversation, speaking in class, and giving speeches.
Parents often describe children with social anxiety as being overly
sensitive to criticism and rejection as well as nonassertive with
peers. Common types of impairment include lack of friends, loneliness,
poor school performance related to lack of participation, school
refusal, and low self-esteem. This disorder is discussed in more
detail in Chapter 72 since it tends to emerge between the ages of
11 and 19 years.
++
Selective mutism is similar to a social anxiety disorder. Children
with selective mutism are reticent to speak in certain situations,
and they consistently fail to speak in 1 or more social settings
(eg, school) despite speaking normally in other settings (eg, home).
They do not warm up after a brief period and start speaking, although
they may engage in nonverbal gestures. Selective mutism can lead
to various problems in school (eg, not answering questions, not
requesting to go to the bathroom), difficulty making friends, family
arguments (eg, child will not speak when requested to speak), and
caregiver strain.
+++
Routine Worries
to Generalized Anxiety Disorder
++
All children have occasional worries; however, when the worries
become excessive and uncontrollable, they are no longer considered normative.
Children with generalized anxiety tend to worry much more than other
children their age, and they are unable to stop worrying. They may
worry about their grades, homework, friends, their health, the health
of others, things going on in the world, and family matters, among
other things. Such children worry even when there is no realistic
reason to be concerned. Insomnia, difficulty concentrating, fatigue,
and irritability are common complaints among children with generalized anxiety
disorder. Other forms of impairment may include a general inability
to enjoy life because of constant worries, difficulty maintaining
friendships, school problems related to concentration difficulties,
and, occasionally, medical problems. For a more detailed discussion
of the diagnosis and treatment of generalized anxiety disorders
see Chapter 72.
++
Fears are common during childhood and generally dissipate over
time and with experience (direct experience and reassuring information from
others). Fears that are considered phobias persist despite experience
and reassurance and are associated with intense distress or avoidance
of the phobic object or situation. The DSM-IV TR divides specific
phobias into 5 categories: animal, such as fear of spiders (arachnophobia);
natural environment, such as fear of lightning and thunderstorms
(astraphobia); situational, such as fear of enclosed spaces (claustrophobia);
blood-injection-injury, such as fear of needles (trypanophobia);
and other, such as fear of school (scolionophobia). The onset of
a specific phobia is usually in childhood or adolescence. The lifetime
prevalence of a specific phobia is 12.5%; the 12-month prevalence
is 8.7%.3a The etiology may be trauma;
for example, being bitten by a dog may result in an irrational fear
of dogs. Phobias may be acquired socially, as in fear of foreigners,
or xenophobia. Specific phobias may also be rooted in biologic or
genetic susceptibility toward anxiety. The treatment of specific
phobia is nonpharmacologic. Cognitive behavior therapy with graduated
exposure to the source of fear is the preferred treatment.
+++
Habits to Obsessive
Compulsive Disorder
++
Habits and rituals are common during childhood. For example,
children may have certain ways of arranging their toys, want to
wear a favorite shirt, or have various bedtime rituals that they
enjoy. The obsessions and compulsions that make up obsessive-compulsive
disorder, however, are more involuntary, less enjoyable, and somewhat
bizarre and nonsensical in nature. Obsessions come in varying forms,
including fears of contamination, need for order or symmetry, pathological
doubting, and recurrent aggressive or horrific images. Common compulsive
behaviors include washing, checking, counting, ordering, asking
for reassurance, and repeating words or actions. Often, children engage
in compulsions to neutralize the unwanted thoughts. For example,
a child may think, “Everything must be lined up perfectly, or
something bad will happen to my mother,” and therefore
engage in excessive ordering rituals to prevent the bad event. Compulsions are
more dominant in younger children, while obsessions in this age
group tend to be more vague (eg, “I had to wash my hands
because I just didn’t feel right”). Obsessions
and/or compulsions must consume at least 1 hour per day and
cause marked distress and/or significant impairment to
be classified as obsessive-compulsive disorder. Like most of the
anxiety disorders, obsessionality exists on a continuum where it
is possible for a child to have traits even if he or she does not
have the disorder. For further discussion see Chapter 72.
+++
Panic Attacks
to Panic Disorder
++
Panic attacks include symptoms (usually 4 or more at the same
time) such as a racing heart, sweating, shaking, shortness of breath,
feelings of choking, chest pain, chills, nausea, dizziness, fear
of losing control or going crazy, and fear of dying. Children with
or without an anxiety disorder can have panic attacks. For example,
children with social anxiety disorder often have panic attacks in
public speaking situations but do not necessarily have panic disorder.
Similarly, a child without an anxiety disorder may have an occasional
panic attack in a given situation but not have panic disorder. The
hallmark feature of panic disorder is a recurrent pattern of unexpected
panic attacks that come out of the blue and do not have a specific trigger.
Panic disorder is associated with subsequent worry about having
another panic attack or a change in behavior because of worries about
having another panic attack. The presence of a behavior change related
to the panic attacks often results in the additional diagnosis of
agoraphobia in which a child avoids certain places (eg, malls, crowded
places, being in a car) for fear that they may have a panic attack and
not be able to escape or get help. Panic disorder usually begins
in late adolescence and is uncommon among young children.
+++
Stressful Experience
to Posttraumatic Stress Disorder
++
Approximately 15% to 35% of children will experience
a traumatic event in their lives; however, most will not develop
a stress disorder on account of this. Children with posttraumatic
stress disorder (PTSD) experienced a traumatic event (eg, varying
forms of abuse, a tragic accident, fire, earthquake or other natural
disaster, violent crimes, seeing somebody else being hurt) that
was upsetting, frightening, life threatening, and outside the realm
of a normal childhood experience. In response, the child reacted
with intense fear, helplessness, or horror. A child with PTSD experiences
flashbacks or recurrent images in the forms of dreams or memories
as well as avoidance of stimuli associated with the trauma. Younger children
may exhibit these behaviors in their play or in their drawings.
Various forms of physiological arousal also become prominent after
the trauma, including irritability, difficulty concentrating, hypervigilance,
difficulty with sleep, and an exaggerated startle response. Related
to PTSD is acute stress disorder, which also occurs specifically
in response to a traumatic event but is different in that the symptoms
must occur within 4 weeks of the trauma and resolve within those
4 weeks. For further discussion see Chapter 72.
+++
Differential Diagnosis
++
Anxiety symptoms are seen in patients with other medical and
behavioral conditions, including substance abuse disorder, autistic spectrum
disorders, attention deficit hyperactivity disorder (ADHD), and
adjustment disorder.
++
Symptoms of anxiety such as chest pain, insomnia, dizziness,
headaches, shortness of breath, nausea, palpitations, and numbness
may mimic medical illnesses such as cardiac disease (eg, mitral
valve prolapse in an adolescent and arrhythmias), hypoglycemia,
pheochromocytoma, vestibular dysfunctions, hypercortisolism, growth
hormone deficiency, thyroid disorders (hyperthyroidism and hypothyroidism),
pulmonary problems, and seizure disorders. It may be challenging
for clinicians to recognize anxiety disorders. Diagnostic accuracy
can be facilitated by considering the context, frequency, and duration
of the child’s anxiety symptoms as well as atypical features
such as age of onset, course, and absence of a family history of
anxiety.
+++
Substance-Induced
Anxiety Disorder
++
Use of central nervous system stimulants like cocaine, amphetamines,
or caffeine or withdrawal from central nervous system depressants
(eg, alcohol, benzodiazepines, marijuana) can produce anxiety-related
symptoms such as panic attacks, phobias, obsessions, or compulsions.
In this case, a diagnosis of an anxiety disorder should be given
only if the symptoms persist long after the effects of intoxication
or withdrawal have resolved.
+++
Autistic Spectrum
Disorders
++
Children with autistic spectrum disorders (ASDs) (see Chapter 92) have difficulties in social relationships
and communication. Children with social anxiety disorder (or selective mutism)
may also demonstrate these behaviors; however, social-anxious children
usually are capable of and interested in forming friendships but
may be unable to do so because of their anxiety. In contrast, a
child with an ASD is often unable to form attachments and/or
lacks interest in social relationships. Children with an anxiety
disorder are usually able to speak appropriately in situations where they
are comfortable, whereas children with ASDs often have speech anomalies
across situations or are unable to speak at all. The repetitive
behaviors that are found in ASDs can seem similar to the compulsions
of obsessive-compulsive disorder. However, compulsions in obsessive-compulsive
disorder are usually more complex and performed to neutralize an obsession.
Children with ASDs often do not experience the behaviors as senseless
and annoying or fear the consequences of not performing the behavior.
++
Anxiety usually predates depression and is often associated with
the onset of depression (see Chapter 93). For example, a socially
anxious child who does not have friends and cannot engage in social
activities may experience feelings of loneliness and low self-esteem
and subsequently become withdrawn and depressed. Where there is
anxiety, a clinician should also ask about depression, and vice
versa. Children with attention deficit hyperactivity disorder (see Chapter 92) are often distracted by extraneous stimuli
(eg, random noises, other kids, trying to get homework done to move
on to something more fun), whereas children with anxiety disorders
are distracted by worries and fears (eg, thoughts like “What
if I say the wrong answer,” “What if my work is
not good enough”) or by rituals, compulsions, or flashbacks.
++
Attention deficit hyperactivity disorder usually has an earlier
age of onset, so if a school-aged child or adolescent suddenly displays
concentration and attention problems that were not there before,
anxiety may be more likely. However, if a child has both attention
difficulties and chronic anxieties (worries, fears, etc), both disorders
may coexist.
++
In an adjustment disorder, the stressor can be of any severity
(eg, romantic break-up, going to a new school, argument with a friend),
and emotional or behavioral impairment occurs in response to a stressor
(within 3 months of its onset). There is significant impairment
greater than expected, and criteria for other diagnoses (eg, major
depression, social anxiety) are not met. Adjustment disorders can
be diagnosed with mood, anxiety, and/or conduct features.