Onset of anxiety disorders in children

There has been relatively little research interest focused on the age of onset and precipitating factors regarding anxiety disorders in children. Relatively more research has been done on these issues for adults, and thus both bodies of research are summarized in this chapter.

Age of onset in children

Table 13.1 summarizes studies in which information concerning age of onset for various childhood anxiety disorders has been found. Separation anxiety disorder, avoidant disorder and simple phobia seem to have the earliest age of onset.

Especially relevant are the recent studies by Biederman et al. (1997) and by Wittchen, Reed & Kessler (1998). Biederman et al. (1997) charted the mean ages of onset of anxiety disorders among children with panic disorder and agoraphobia. They examined 472 consecutively referred children and adolescents via a structured diagnostic interview. These children and adolescents were referred to a paediatric psychopharmacology clinic that did not specialize in the treatment of any particular disorder. Among children with agoraphobia the earliest anxiety disorder to emerge was specific phobia, followed by avoidance disorder and separation anxiety disorder; each of these disorders preceded the onset of agoraphobia. Overanxious disorder, social phobia and obsessive–compulsive disorder tended to follow the emergence of agoraphobia. Children with panic disorder showed a similar course, but they showed slightly later ages at onset for all the disorders. Agoraphobia had an earlier age at onset than panic disorder. This last finding was confirmed in the community study by Wittchen et al. (1998).

Introduction

Epidemiological and clinical studies have indicated that the prevalence of the different anxiety disorders is related to age, and that the average age-at-intake and age-at-onset also differ for the various anxiety disorders. At the same time, however, virtually any anxiety disorder may occur in any age cohort. This chapter addresses the question whether the differences both between and within age cohorts may be explained in terms of general theories of psycho-social development.

The following age pattern was observed for nonphobic anxiety disorders (Kashani & Orvaschel, 1990; Last et al., 1987; Westenberg et al., 1999; see also American Psychiatric Association (APA), 1987, 1994): (a) separation anxiety disorder (SAD) occurs most frequently in childhood, (b) overanxious disorder (OAD) ismost characteristic of adolescence and (c) panic disorder (PD) appears most frequent in late adolescence and (young) adulthood. Yet, SAD may also occur in adolescence, and PD may occur even in childhood (Ollendick, 1998). DSM-IV no longer includes OAD, and merged this classification with Generalized Anxiety Disorder (GAD; APA, 1994). However, the core criteria and the clinical features of OAD are highly similar to those in children with GAD (see APA, 1994). Tracey et al. (1997) observed that ‘DSM–IV GAD criteria are identifying the same sample as the DSM–III–R OAD criteria’ (p. 409).

The production of this volume was prompted by the international research conference on anxiety disorders in children and adolescents, held in Leiden, The Netherlands, May 15 and May 16, 1997, under the auspices of Curium, Academic Centre of Child and Adolescent Psychiatry, Leiden University, the Section of Child and Adolescent Psychiatry, Netherlands Psychiatric Association, and the Netherlands Institute for Postgraduate Studies. With the exception of chapters 1, 5, 11, and 15, the chapters in this volume began as papers presented at the conference. Each of these however has been extensively revised or fully rewritten, partly in response to feedback from the editors. The other chapters were specially invited contributions (except for chapter 1 which was written by the editors) intended to balance the thematic organization of the book.

As the programme committee for the conference and the editors of this volume, it was a privilege for us to work with such a distinguished group of scholars. In our view, each contributor successfully met the challenge of analysing and synthesizing the particular literature relevant to their chapter. As a consequence, each chapter represents an excellent treatise of a topical area. As a corpus of work, the volume thus provides for a thorough and complete summary of current issues and perspectives about anxiety disorders in children, and therefore advances our understanding about anxious children.

We believe it is important and useful to have a volume that provides this type of integrative summary of the various literatures relevant to anxiety and its disorders in children and adolescents because these literatures have grown considerably in recent years. Because of this growth, it has become increasingly difficult to keep up with the knowledge base.

Introduction

Little Hans and little Albert are so well-known that one might easily get the impression that Freud (1909) and Watson (Watsony & Rayner, 1920) were the first to ‘discover’ anxiety and its disorders in children. This impression is likely to be reinforced by a reading of the contemporary child psychiatry and psychology literatures. These literatures are basically characterized by an absence of any mention about the existence of anxiety and its disorders as phenomena that existed in childhood prior to the year 1900. Klein & Last (1989) are among the few contemporary authors to note that anxiety and its disorders in children were mentioned by others as existing before this time period (they refer to Kraepelin (1883) and Emminghaus (1887) as the first authors to report anxiety states in children and adolescents).

In this first chapter, we present a historical perspective of anxiety and its disorders in childhood and adolescence in terms of how they were viewed in psychiatry and psychology prior to the twentieth century. We chose to focus our attention on this time period because we were more interested in exploring ‘uncharted waters’ than charted waters. That is, as noted, we believe most readers are already generally familiar with the main developments that occurred during the twentieth century (e.g. Little Hans and Little Albert).