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SOMETHING TO WORRY ABOUT: ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS

By Martin Drell, M.D.

"Alexandria gets so worried about her tests at school that she develops severe headaches. Nothing I say seems to relax her tension. What should I do?"

"John complains of stomach aches all during the school week, but on the weekends he feels fine. Then, on Sunday night, they come back again. Just when I think he's trying to avoid going to school, he actually throws up. What should I do?"

Anxiety disorders of children and adolescents represent a burgeoning area of research. In recent years, this research has revealed not only that large numbers of children are affected by these disorders (estimated at 5-10%), but that those with the disorder suffer greatly.

The current interest in anxiety research is due to a shift in how researchers conceptualize these disorders. In the past, interest focused more on the emotional and interpersonal conflicts people had with themselves and those important to them. It was thought that these conflicts led to a host of symptoms including anxiety, depression, and anger. The majority of efforts were spent trying to deal with these conflicts. It was felt that, if the conflicts were alleviated, then the symptoms would automatically modify or resolve.

Recently, researchers have turned things upside-down. Rather than focusing on the conflicts they have begun to focus on the various symptoms. They have attempted to classify disorders according to various groupings of these symptoms and to ask questions such as:

1. Are children with one group of symptoms different from those with other groupings? Is this a diagnosis that is a distinct entity?
2. Do children with certain groups of symptoms have relatives with the same groups of symptoms? Is this a genetic disorder or does it run in families for other reasons?
3. Do children with certain groups of symptoms continue to have them over time? Is this more than a transient developmental disorder?
4. Do children with certain groups of symptoms tend to have other associated problems?
5. Do these groups of symptoms seem to have common factors preceding them whether this be specific events, types of family interactions, or changes in brain structure treatments?
6. Do children with these groups of symptoms respond to specific treatments?

Much has been learned from this new focus and the information it has generated. We now believe that anxiety disorders are a set of disorders characterized by "an unjustified and unpleasant sense of apprehension" accompanied by bodily reactions (blood pressure changes, increased heart rate, changes in blood flow, etc.), a feeling of overwhelming dread, fear or doom, and changes in thinking.

These disorders are found in persons of all ages often with differing presentations depending on the age. In essence, children may have them but not necessarily look exactly like adults with the same disorder. Research shows that these disorders are much more common than we thought and that they run in families. We know that there are lots of people with these disorders who are not receiving treatment. It is thought that many feel that this is "just the way they are" and that their level of anxiety is normal. They have never felt otherwise so how would they know?

Likewise, because anxiety disorders run in families, they may be disregarded as being normal for the entire family (e.g, "We're all worriers"; "We're all high-strung"). Research has also shown us that persons with one anxiety disorder tend to have other emotional disorders including other anxiety disorders.

Studies further show that persons with some anxiety symptoms, but not enough symptoms to be diagnosed as having an official disorder, have very real problems coping with various aspects of their lives. In summary, these are real disorders that tend to run in families, cause problems, and often continue over time. Anxiety disorders commonly seen in children and adolescents include:

This is a biologically influenced disorder characterized by discrete periods of intense fear or discomfort that develop abruptly, often without a logically identifiable cause. Children with panic attacks can have palpitations, sweating, trembling, shortness of breath, a feeling of unreality, fears of death, chills, and tingling sensations. Younger children, who have difficulty expressing how they feel, are often taken to pediatricians with physical complaints that are often gone by the time of the appointment. This disorder is frequently misdiagnosed and leads to unwarranted laboratory and psychiatric tests.

This disorder is characterized by excessive and inappropriate anxiety concerning separation from home and from important caregivers. Children with this disorder are severely distressed when their caregivers leave them and worry that something terrible will happen to either them or their loved ones during the separation. These worries lead to changes in the normal routines of life often including a refusal to go or to stay in school, difficulties going to sleep and staying asleep, refusal to sleep other than with the caregiver, and physical complaints (headaches, stomach aches, nausea, and vomiting) in anticipation of separations (n.b. physical problems on Monday mornings right before school is a classic presentation).

This disorder was formerly called "Over-Anxious Disorder." It is manifested by excessive and unrealistic worry that lasts for more than six months. These children are "worry warts" who ruminate on what's happened in the past and what will happen in the future. They often feel inadequate and not up to the rigors of everyday life which make them anxious and often physically ill (tenseness, headaches, stomach aches, nausea, etc.). These children are often overwhelmed, unhappy, and unsuccessful.

This disorder is manifested by recurrent obsessions (defined as persistent ideas, thoughts, images, or impulses that are experienced as intrusive and senseless) or compulsions (defined as repetitive intentional behaviors that are performed on response to the obsessions). The obsessions and compulsions cause marked distress and can consume the majority of the child's time in non-productive pursuits such as hand washing, checking and counting rituals, word games, gestures, and fears that the child has done something awful.

This disorder begins after a trauma that involves an actual or perceived threat of death or serious injury to the child or others. The children appear to have difficulty getting over the event and suffer from recurrent and intrusive memories of the trauma, recurrent nightmares, flashbacks, intense distress when exposed to anything that reminds them of the trauma, a persistent state of arousal (irritability, increased heart rate, difficulty concentrating, easily startled), and attempts to avoid anything that reminds them of the trauma.

This disorder involves a persistent and ongoing fear of situations in which the child's fears are being exposed to possible scrutiny (e.g., public speaking, eating in public) and potential humiliation. The anxiety causes children with social phobia to curtail their activities even if these activities are part of normal existence, like speaking in class. Research shows that this disorder is especially prevalent in children who were "extremely shy" when young. This disorder is closely tied to another disorder called selective mutism in which children consistently fail to speak in specific social situations, despite having no trouble speaking in other situations.

A disorder in which there is a persistent, excessive, and unreasonable fear of a specific object (i.e., cats, cockroaches, etc.). This fear interferes with everyday life. This is more than your run-of-the-mill fear of bugs, and the normal, yet transient, fears often seen in young children.

If you suspect that your child has an anxiety disorder, you should consider an evaluation by a mental health professional. The rapid increase in knowledge about these disorders has luckily included an increased knowledge on how to treat them. Treatment programs that involve work with individual children, their families, and often their schools, as well as the use of medications in specific instances are often most helpful in alleviating and resolving anxiety disorders. Children and their families do not have to suffer endlessly from the ravages of anxiety.

References

Livingston, R., "Anxiety Disorders" in Child & Adolescent Psychiatry: A Comprehensive Textbook. 2nd edition - Edited by Melvin Lewis. Baltimore: Williams & Wilkins, 1996, pp. 674-683. Diagnostic and Statistical Manual IV, Washington, DC, APA Press, 1996.

Dr. Martin "Marty" Drell is head of Child and Adolescent Psychiatry, LSU School of Medicine, New Orleans, and editor of the professional journal for the American Academy of Child and Adolescent Psychiatry.