Anxiety disorders in children and adolescents: Need for early detection.

Anxiety is a normal human emotion and involves behavioral, affective, and cognitive responses to the perception of danger. It is considered to be excessive or pathological when it is out of proportion to the challenge or stress or when it results in significant distress and impairment.[1] It is viewed as a normal part of childhood. Children experience fear, nervousness, shyness, and avoidance of places and activities that persist at times despite the helpful efforts of parents, caretakers, and teachers. Anxiety disorders are one of the most common disorders seen among children and adolescents. The prevalence of anxiety disorders ranges from 4% to 20%.[2] Common anxiety disorders among children are specific phobia, social phobia, generalized anxiety disorder, and separation anxiety disorder having mean prevalence rates between 2.2% and 3.6%. Agoraphobia (1.5%) and post-traumatic stress disorder (1.5%) are less prevalent, whereas panic and obsessive–compulsive disorders are relatively rare (i.e., below 1%).[3]

The current study[4] found anxiety symptoms more in older children which was in contrast to European studies. Girls have higher prevalence compared to boys, and this difference gets accentuated with development and reaches 2-3:1 by adolescence.[5] This was not supported by the current study.[4] There is a need to conduct a wider survey taking samples from different types of schools to determine the exact role of age and gender in the prevalence of anxiety disorders.

The current data on the prevalence of anxiety disorders among school-going children and adolescents in India is lacking. This study[4] has done a commendable job in providing this data.

Social milieu also effects anxiety disorders as has been found in various studies. This study revealed a high prevalence of anxiety disorders among school-going children belonging to middle and upper classes in a metropolitan city emphasizing the need to conduct a study in different metropolitan cities as well as among children in rural areas.

The earliest report on psychiatric morbidity in pediatric population observed neuroses in approximately 18% of the study population.[6] Recently, a multidimensional ICMR study reported the prevalence of simple phobia as 1.98–2.9% and all other anxiety disorders at less than 1%.[7] Difficulty in coping with studies, concern about weight, having less friends, lack of intimacy with parents, and being treated differently from siblings were associated factors.[8] The current study[4] included only average students which helped in reducing bias by excluding outliers. There is a need to study the role of important variables such as school and board exams in the prevalence of anxiety symptoms as well as the impact of anxiety on the academic performance of children.

Hereditary and environmental factors and cognitive bias play a role in the etiology of anxiety disorders. Childhood anxiety disorders are transitory but in some they can be chronic and persistent often with a waxing and waning course and “syndrome shifts.”[9] The pure form of anxiety disorder decreases with rise in secondary psychopathology such as depressive or substance use disorders by late adolescence or early adulthood. Depression is more than 8 times as likely in youths with anxiety disorders than in those without anxiety disorders.[10] The current study had a higher number of older children with obsessions; a previous history of anxiety symptoms in early ages needs to be evaluated to determine if this was a continuum to secondary psychopathology. Moreover, variables such as peer pressure, family dynamics, as well as history of psychiatric illness or history of any traumatic event can also be studied for better perspectives in a child's anxiety behavior.

The current practice recommends screening, rating severity, and assessing functional impairment among young for anxiety disorders, and to look for comorbid psychiatric conditions as well as for general medical conditions (e.g., hyperthyroidism) that may mimic anxiety symptoms.[11] This evaluation also differentiates from developmentally appropriate worries, fears, and responses to stressors and presence of stressors or traumas are considered to determine their contribution to the development or maintenance of anxiety symptoms.

Multidimensional Anxiety Scale for Children, Screen for Child Anxiety and Related Emotional Disorders (SCARED), and the Spence Children's Anxiety Scale (SCAS) (child self-report measures), Pediatric Anxiety Rating Scale (a clinician-rated measure), and Preschool Anxiety Scale (a parent report) are sensitive and specific tools for assessing anxiety as well as for monitoring treatment progress.[121314] As suggested by the current study,[4] there is a need to develop standardized screening tools in India that are validated in local languages to include a wider range of sample.

Management strategies involve both nonpharmacological approach as well as pharmacotherapy. A large multicenter study observed that participants who were on combined treatment [cognitive behavior therapy (CBT) with sertraline] not only showed better response but also maintained the same at 24 and 36 weeks of follow-up.[15] CBT has now been examined in very young children (preschoolers) with anxiety disorders with better response. Pharmacotherapy can be employed especially during the acute phase or in very severe stage, or in poor response to CBT but otherwise nonpharmacological approach is still regarded as the treatment of choice for childhood anxiety disorders. In the current scenario, where continual performance is considered to be the key to success, parents and environment put a lot of pressure on a child resulting in anxiety; at times parents’ anxiety is projected over their kids. This can be harmful in the long run, and in authors' experience, are major contributors towards increase in childhood mental health problems, which can be as severe as suicide. Probably, steps from the micron level to the national level to reduce this pressure can hold better future for these young children.

There is evidence that childhood anxiety disorders are at the outset of a “cascade of psychopathology,” therefore, there is a need for early recognition and treatment. In addition to adverse long-term psychopathological outcomes, it also causes impairment in functioning as well hampers general health, resulting in financial, interpersonal, and educational difficulties. It is clear that an understanding of the pathways – how they develop, maintain, and remit – requires consideration. More longitudinal studies are needed to further expand our knowledge on this highly prevalent type of psychopathology.