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Research Journal, Part 3
Scholarly Articles
Value: 20 points
In this assignment, you will explore your research topic/question using a scholarly journal articles and answer a series of question to reflect on each article you find. Using what you learned in your in-class workshop, search Academic Search Complete for articles that will help you with your updated research question. All three articles should be scholarly/peer-reviewed. It’s important that you search carefully, using thoughtful key words, narrowing using database limiters like subject terms and dates, and evaluating the content of the articles you locate before making your selection. Be sure you save your assignment as a Word file and.
Scholarly Source #1
1. MLA Citation (1 point)
2. Author/Editor Reflection (4 points)
First, be sure you have selected a scholarly source and not a source from a newspaper, magazine, or other popular source. Your first sentence will articulate how you know this a scholarly source.
You will likely have to search for the author or editor online to find this information. Write a brief 4-6 sentence paragraph including all of the following: The author’s name and qualifications for writing about this subject, whether you feel this author is qualified to write about this subject and why. Besides a person with this professional background, who else (by profession, identity, or experience) might provide an additional angle on your research question? For example, if this person is an academic expert in psychology, what different angle would an expert in another subject bring? Or if this is an academic source, would you like to hear from a news source or from someone with personal experience? Why?
Scholarly Source #2
3. MLA Citation (1 point)
4. Evidence Reflection (4 points)
First, be sure you have selected a scholarly source and not a source from a newspaper, magazine, or other popular source. Your first sentence will articulate how you know this a scholarly source.
Write a brief 4-6 sentence paragraph including all of the following: List all the types of evidence used in this source (e.g., quotes/summaries from other sources, summaries of case studies, statistics etc.). Choose two pieces of evidence used in this article and explain how this evidence supports the author’s purpose in writing, their argument, or how it otherwise contributes to the overall article. Selectively quote the evidence in your discussion ie., do not quote multiple sentences or long sentences but only the most necessary parts for your examination.
Scholarly Source #2
5. MLA Citation (1 point)
6. Search terms Reflection (4 points)
First, be sure you have selected a scholarly source and not a source from a newspaper, magazine, or other popular source. Your first sentence will articulate how you know this a scholarly source.
Write a brief 3-5 sentence paragraph about your process for finding and selecting the article. First describe your initial set of search terms, how you selected these and a description of the results. Then, change these search terms and evaluate your new results and explain how they’re different and why these new terms affected your search results. Describe how you limited your search results by subject, date, etc. and explain why you chose the limiters you did . Finally explain how this source contributes to your research by providing answers to your question, filling in gaps in your own knowledge, or in some other way
7. Research Journal: Provide two sentences per answer. (4 points)
· Do all your resources seem to agree with one another? If not, on what points do they differ and what is your opinion? If they do all agree you likely need to seek out another perspective. Reflect on how you might best do this (where will you find it, what search terms will you use, what might that perspective be?)
· What is one new thing you learned about your topic that other people might find interesting or might be controversial?
8. Looking Ahead (1 point)
· What was the best part of the workshops?
· What was your least favorite part of the workshops?
j3/scholarly1.pdf
836 EVANS, THIRLWALL, COOPER, AND CRESWELL
in treatment trials for childhood anxiety disorders (Ginsburg et al., 2011; Hudson et al., 2014). However, the ADJS-IV-C/P requires trained clinicians and considerable time to administer (averaging 134 min where children are clinically anxious; Lyneham & Rapee, 2005). It is therefore common for self- and parent-report question naires to be used in routine clinical practice (Children and Young People’s Improving Access to Psychological Therapies [CYP- IAPT], 2011). Self-report measures have the advantage of being relatively quick to deliver and do not require trained clinicians to administer (Simon & Bogels, 2009). However, the extent to which outcomes as assessed by these child and parent report measures of child anxiety reflect recovery as assessed by semistructured diag nostic interviews is unknown.
Receiver operating characteristic (ROC; Swets, 1988; Zweig & Campbell, 1993) methods can assess the accuracy of measures at identifying diagnoses according to established gold-standard diag nostic tools. As well as generating a score indicating a measure’s overall accuracy at identifying diagnoses (the area under the curve [AUC]), ROC can be used to identify optimum cut-off points for a measure. At each cut-off point for a given measure and diagno sis, the proportion of ‘true positive’ (sensitivity) and ‘true nega tive’ (specificity) individuals can be calculated. Previous recom mendations for the field of child anxiety disorders have highlighted both the potential value of ROC for evaluating mea sures and the lack of research utilizing this method (Silverman & Ollendick, 2005).
Where ROC has been used, this has primarily been for screening purposes rather than assessing response to treatment for anxiety disorders. For example, parent and/or child report questionnaires have been identified as moderate to good screening tools for ADIS-1V-C/P social phobia and separation anxiety disorder diag noses in children on the basis of ROC methods (Bailey, Chavira, Stein, & Stein. 2006; Villabp, Gere, Torgersen, March, & Kendall, 2012). However, the presence of any anxiety disorder has been found to be identified poorly by child reported anxiety symptoms (using the Multidimensional Anxiety Scale for Children; MASC; March, Parker, Sullivan, Stallings, & Conners, 1997) although mother report on this measure was slightly superior and therefore considered a fair measure (Villabp et al., 2012).
Although there has been some consideration of the utility of child anxiety questionnaires as screening tools, there has been little examination of their ability to identify recovery. Nonetheless self- and parent-report measures are frequently used to assess treatment outcomes (CYP-LAPT, 2011). It is clearly important that guidance is provided for clinicians on the accuracy of commonly used questionnaires at identifying recovery from anxiety disorder diag noses including cut-offs with good sensitivity and specificity. The utility of ROC for this purpose has been demonstrated in an evaluation of the clinician-rated Pediatric Anxiety Rating Scale (PARS; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002) as a measure of recovery from anxiety disor ders in children (Caporino et al., 2013).
Given the widespread use of child and parent report question naires to assess treatment outcomes in clinical practice, we set out to establish the utility of two commonly used measures (Spence Child Anxiety Scale; SCAS-C/P; Nauta et al., 2004; Spence, 1998; Child Anxiety Impact Scale; CAIS-C/P; Langley, Bergman, Mc Cracken, Piacentini, 2004; Langley et al., 2014) to identify recov ery from anxiety disorders on the basis of the ADIS-IV-C/P using
data from two treatment trials for child anxiety (Creswell et al., 2015; Thirl wall et al., 2013).
The SCAS-C/P was selected because this is a widely used measure of child anxiety symptoms (in its own right and in an adapted form in the Revised Child Anxiety and Depression Scale; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000). Given that functional impairment is critical in distinguishing anxiety disorder diagnoses from typical fears and worries (APA, 2013), we also elected to include a questionnaire measure of interference associ ated with anxiety. The CAIS-C/P is a measure of the extent to which a child’s anxiety impacts on their daily functioning in school, social and home contexts. It has been used to evaluate characteristics of anxious children (Kendall et al., 2010) and to inform evaluation of the clinician-rated PARS as a measure of response to treatment for child anxiety (Caporino et al., 2013).
A further methodological consideration is related to the facts that (a) comorbidity of anxiety disorders in children is common (Waite & Creswell, 2014), and (b) the primary outcome used across trials are typically either being free of a particular anxiety disorder (e.g., social phobia), being free of the most impairing (‘primary’) anxiety disorder, or being free of all anxiety disorders. For these reasons we used ROC methods to establish the ability of the CAIS-C/P and the SCAS-C/P to identify recovery, following treatment or a wait-list control, on the basis of each of these three criteria, focusing on the four most common anxiety disorders in childhood (separation anxiety disorder, social phobia, generalized anxiety disorder, and specific phobia). We evaluated both child and parent measures, because both are commonly used in routine clinical practice (CYP-1APT, 2011) and because it is possible that diagnostic outcomes as assessed by the ADIS-IV-C/P in its stan dardized form may align more closely with parent than child report for preadolescent children. Indeed the ADIS-C/P, as standard, involves allocating a diagnosis if criteria are met on the basis of either child or parent report and these ‘overall’ diagnoses have previously been found to be more closely associated with out comes from parent than child interviews (Grills & Ollendick, 2003). With these considerations in mind, this study set out to examine the extent to which child and parent report on the SCAS- C/P and CAIS-C/P reflected measures of recovery as assessed by the ADIS-C/P semistructured diagnostic interview.
Method
Participants
Participants were 337 children aged 7 to 12 years (M = 9.72, SD = 1.55) and their primary caregivers (334 mothers, 3 fathers). One hundred fifty-nine of the children were recruited as part of a randomized controlled trial (RCT) comparing two guided parent- delivered cognitive-behavioral treatments (GPD-CBT) of varying intensity to a wait-list control (Thirlwall et al., 2013). The remain ing 178 of the children participated in an RCT comparing child CBT (CCBT) alone versus CCBT supplemented by CBT for maternal anxiety disorder (CCBT + MCBT) or treatment focused on the mother-child interaction (CCBT + MCI) (Creswell et al., 2015). Because the aim of this study is to evaluate the accuracy of self-report measures at identifying recovery from child anxiety disorders broadly, rather than in the context of a specific interven tion, children from all treatment conditions across these two trials
RECOVERY FROM CHILD ANXIETY DISORDERS 837
were included. Further details of the sample are shown in Table 1. Table 2 shows the number of participants who completed each measure at each time point. Those who did and didn’t complete each measure at each time were compared on key demographic and clinical characteristics and no consistent, significant patterns were found.
Procedure
All children were referred by primary and secondary NFIS/ education services to Berkshire Child Anxiety Clinic, University of Reading, UK. The children in the first trial (Thirlwall et al., 2013) were assessed before (Time 1) and after (Time 2) eight- session GPD-CBT (n = 50), four-session GPD-CBT (N = 46), or a 12-week wait-list (n = 63). The children in the second trial (Creswell et al., 2015) were assessed before (Time 1) and after (Time 2) eight-session CCBT (n = 56), eight-session CCBT + MCBT (n = 60), or 10-session CCBT + MCI (n = 62). All children and primary caregivers completed the ADIS-1V-C/P at Time 1 and Time 2 in all conditions. However, not all respondents
Table 1 Demographic Characteristics o f the Sample (N = 337)
Characteristic N %
Gender Male 164 48.7 Female 173 51.3
Ethnicity White British 289 85.8
Parental marital status Married, remarried, living with partner 254 75.4 Single parent 74 21.4 Not stated 9 2.7
Socio-economic status of family Higher/Professional 192 57 Other employed 99 29.4 Unemployed 10 3 Not stated 36 10.7
Presence of common anxiety diagnoses Separation anxiety disorder 190 56.4 Social phobia 217 64.4 Generalized anxiety disorder 212 62.9 Specific phobia 156 46.3
Child primary diagnosis (ADIS-IV-C/P) Separation anxiety disorder 81 24 Social phobia 73 21.7 Generalized anxiety disorder 92 27.3 Specific phobia 62 18.5 Other anxiety disorders 29 8.7
Child primary diagnosis CSR Moderate (CSR 4) 31 9.2 Moderate (CSR 5) 93 27.6 Severe (CSR 6) 175 51.9 Severe (CSR 7) 36 10.7 Very severe (CSR 8) 2 .6
Presence of other psychiatric disorders (ADIS-IV-C/P) Dysthymia 18 5.3 MDD 28 8.3 ADHD (all types) 46 13.6 ODD 64 19
Note. CSR = clinical severity rating; MDD = major depressive disorder; ADHD = attention-deficit hyperactivity disorder; CD = conduct disorder; ODD = oppositional defiant disorder.
completed the CA1S-C/P and SCAS-C/P at both time points (total n for each measure ranged from n = 247-320).
Measures
Anxiety Disorders Interview Schedule for /J.S'M-/V/-Chikl and Parent Versions. Children were assigned diagnoses based on the Anxiety Disorders Interview Schedule for DSM-IV for Children- Child and Parent Versions (AD1S-IV-C/P; Silverman & Albano, 1996). The ADIS-1V-C/P is a clinician-administered semistructured interview to assess for DSM-IV anxiety, mood, and externalizing disorders in children and adolescents. The reliability and validity of child and parent versions of the ADIS-IV-C/P has been established (Silverman, Saavedra, & Pina, 2001; Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). In line with the DSM-IV, the ADIS-IV-C/P includes questions regarding both symptoms and functional impairment associated with anxiety. Clinicians assign Clinical Severity Ratings (CSR) for each anxiety disorder following ADIS-IV-C/P interviews on a scale of 0 (com plete absence o f psychopathology) to 8 (severe psychopathology). As is conventional and recommended in the ADIS-IV-C/P clini cian manual (Albano & Silverman, 1996), children were assigned diagnoses where the CSR was 4 (moderate psychopathology) or greater on the basis of either child or parent report and the higher of the two was allocated. The anxiety disorder with the highest CSR was allocated as the primary disorder. The assessors were all psychology graduates (BSc/MSc in psychology) and were trained to administer and score the ADIS-IV-C/P through listening to audio-recorded assessments, role-plays, verbal instructions, and consensus meetings. In both trials, assessors were blind to treat ment condition, and at least the first 20 interviews of each assessor were discussed with a consensus team before formal reliability checks. After assessors had achieved reliability of k = .85, one in every six interviews was discussed with the consensus team to prevent rater drift. Interrater reliability for the team in assigning individual diagnoses at posttreatment was excellent (child report diagnosis: k = .94-99 parent report diagnosis: k = .97-98).
Spence Children’s Anxiety Scales. The Spence Children’s Anxiety Scales (SCAS-C/P; Nauta et al., 2004; Spence, 1998) are parent- and child-report scales comprising 38 items referring to common symptoms of child anxiety disorders. A number of sub scales are formed from these 38 items. Relevant to the present study, six of the items form a separation anxiety subscale (SCAS- C/P-SA), six form a social phobia subscale (SCAS-C/P-SP), six form a generalized anxiety subscale (SCAS-C/P-GA), and five form a physical injury fears subscale (SCAS-C/P-PI) which is relevant to specific phobias. Respondents are asked to indicate how accurate each of the 38 statements are on a 4-point scale of never, sometimes, often, and always. The child and parent versions are identical apart from adjustments to make the wording suitable for each and the inclusion of ‘filler’ items in the child version. The SCAS-C/P has been widely used and established as having good concurrent validity (Whiteside & Brown, 2008), discriminant va lidity (Nauta et al., 2004; Spence, 1998; Whiteside & Brown, 2008), convergent validity with other commonly used measures (Essau, Muris, & Ederer, 2002; Nauta et al., 2004; Spence, 1998; Whiteside & Brown, 2008), and acceptable test-retest reliability (Spence, 1998). The good psychometric properties of the SCAS- C/P have been established in children aged 6 to 18 years (Spence,
838 EVANS, THIRL WALL, COOPER, AND CRESWELL
Table 2 Descriptive Statistics and Cronbach's Alphas for Child and Parent Report Anxiety Measures at Time 1 and Time 2
Measure
Time 1 Time 2
N M SD a N M SD a
SCAS-C total 320 39.30 18.38 .91 294 27.12 16.37 .93 SCAS-C separation anxiety subscale 323 8.65 3.94 .64 301 5.66 3.86 .78 SCAS-C social phobia subscale 320 7.48 3.92 .73 293 5.30 3.76 .71 SCAS-C generalized anxiety subscale 320 8.24 3.51 .73 294 6.12 4.50 .81 SCAS-C physical injury fears subscale 320 5.48 3.23 .51 294 4.12 2.71 .44 SCAS-P total 308 40.03 16.15 .88 247 23.56 12.30 .90 SCAS-P separation anxiety subscale 307 10.42 3.45 .52 251 6.62 3.13 .59 SCAS-P social phobia subscale 307 9.95 3.92 .74 246 7.25 3.46 .78 SCAS-P generalized anxiety subscale 308 8.74 3.45 .73 248 5.26 2.80 .76 SCAS-P physical injury fears subscale 308 5.89 3.17 .47 248 3.93 2.70 .57 CAIS-C total 319 18.34 13.90 .52 294 12.73 13.12 .94 CAIS-P total 283 19.57 14.66 .70 250 12.02 11.23 .90
Note. Subscale scores are given for children with relevant diagnoses at Time 1. SCAS-C = Spence Children’s Anxiety Scale (child report); SCAS-P = Spence Children’s Anxiety Scale (parent report); CAIS-C = Child Anxiety Impact Scale (child report); CAIS-P = Child Anxiety Impact Scale (parent report).
1998; Nauta et al., 2004), and it has been widely used with chil dren of the age range considered here (e.g., Hudson et al., 2014; Vigerland et al., 2016). In the present sample, internal consistency was good for total SCAS-C/P total scores at Time 1 and Time 2 (a = .88-.93), although was more variable for subscales (see Table 2).
Child Anxiety Impact Scales. The Child Anxiety Impact Scales (CAIS-C/P; Langley et al., 2004; Langley et al., 2014) are 33-item parent- and child-report measures, containing 27 items which refer to impact within three categories; school activities, social activ ities, and home/family activities. Four items relate to global impact. Respondents are asked to indicate on a 4-point scale the extent to which anxiety has caused trouble with each activity (i.e., ‘not at all,’ ‘just a little,’ ‘pretty much,’ or ‘very much’). Parent and child versions are identical apart from minor changes to wording. The CAIS-C/P has been shown to have good internal consistency and convergent validity with other measures of child anxiety (Langley et al., 2014). The psychometric properties of the CAIS-C/P have been established in children aged 7 to 17 years (Langley et al., 2004, 2014). Internal consistency was good for CAIS-P at Time 1 and 2 and for CAIS-C at Time 2 in the present sample (a = .70-.94) but not Time 1 (a = .52; see Table 2).
Data Analysis
Consistent with existing literature evaluating the accuracy of mea sures at identifying diagnoses by the ADIS-IV-C/P (Bailey et al., 2006; Caporino et al., 2013; Villabp et al., 2012), and recommenda tions for this area of research (Silverman & Ollendick, 2005), ROC (Swets, 1988; Zweig & Campbell, 1993) methods were used to determine the ability of Time 2 total scores on the parent and child versions of the CAIS and SCAS, plus subscales of the SCAS, to identify recovery according to the ADIS-IV-C/P. Analyses were also conducted using change scores between Time 1 and Time 2, but no clear advantage was found of looking at these over Time 2 scores alone so we have focused our report on Time 2 scores. Furthermore, analyses were conducted separately on the two trials and just on the children who received treatment (i.e., excluding those in wait-list conditions). No clear or systematic differences were found in the results of any of these groups compared with the
overall 337 children (see the Appendix for results with treated group only). Therefore, only the results of analyses with these 337 children are presented.
A number of values are generated from ROC methods. The AUC is a single global indicator of a test’s ability to correctly classify individuals’ diagnostic status, with an AUC of 1.0 indi cating a perfect test and .50 indicating a test which classifies individuals at chance level. AUCs of .70 to .74 have been de scribed variously as moderate (van Gastel & Ferdinand. 2008), fair (Villabp et al., 2012), and as representing a large effect size (Rice & Harris, 2005). The present study therefore used an AUC of .70 as the minimum value for a measure to be considered at least moderately accurate at identifying recovery from diagnoses ac cording to ADIS-IV-C/P. For each diagnostic outcome, results of analyses using ROC methods are only presented for measures which achieved an AUC exceeding .70. MedCalc for Windows (Version 15.6) was used to establish that all ROC analyses in cluded sufficient numbers of children with both positive and negative outcomes to achieve an AUC of .70.
ROC analyses also generate sensitivity and specificity values which, in the context of this study, indicate the ability of each questionnaire (CAIS/SCAS) to correctly identify children who have recovered from a diagnosis and children who have retained a diag nosis, respectively, on a scale of 0 to 1. In the present context, a higher cut-off score leads to greater sensitivity and lower specificity whereas a lower cut-off score results in lower sensitivity but greater specificity. To minimize the risk of children who retained diagnoses being incor rectly classified as recovered, the highest cut-off score with a speci ficity of at least .70 was selected for each measure.
Results
At the Time 2 (posttreatment/wait list) assessment, 47% of children no longer had the primary diagnosis they had been assigned at Time 1, and 27% were free of all anxiety disorders. Of the children diag nosed with separation anxiety disorder at Time 1. 53% were recov ered from this diagnosis at Time 2. The equivalent figures for recov ery from social phobia, generalized anxiety disorder, and specific phobias at Time 2 were 37%, 60%, and 39%, respectively.
RECOVERY FROM CHILD ANXIETY DISORDERS 839
Identifying Absence of All Anxiety Diagnoses With Time 2 SCAS-C/P and CAIS-C/P Scores
Although SCAS-C, SCAS-P and CAIS-P all achieved AUCs exceeding .70 for identifying absence of any anxiety diagnoses, both the SCAS-C and SCAS-P showed relatively poor sensitiv ity at their respective cut-off scores of 22 and 18. However, the CAIS-P achieved an AUC of .81 which, along with acceptable sensitivity (.70) and specificity (.70) values, indicates that a CAIS-P score of below 7 is a good indicator that a child has no anxiety diagnoses as determined by the ADIS-IV-C/P (see Table 3).
Identifying Recovery From Primary Diagnosis With Time 2 SCAS-C/P and CAIS-C/P Scores
As shown in Table 3, the only measure to achieve an AUC exceeding .70 for identifying loss of primary diagnosis was the CAIS-P at a cut-off score of 8. However, the relatively poor sensitivity at this cut-off (.61) limits the extent to which it can be considered useful for this outcome as it indicates that a consider able proportion who recovered from their primary diagnosis actu ally had CAIS-P scores exceeding 8.
Identifying Recovery From Particular Anxiety Diagnoses With Time 2 SCAS-C/P and CAIS-C/P Scores
As shown in Table 3, recovery from separation anxiety disorder was successfully identified by both child (AUC = .80) and parent (AUC = .82) reports on the SCAS separation anxiety subscale. The (total) CAIS-P score was only marginally less successful (AUC = .79) at a cut-off point of 12. All three of these measures also achieved acceptable sensitivity (.70-76) and specificity (.71- .73) at their respective cut-off scores, meaning they can be con
sidered as moderate to good at identifying recovery from separa tion anxiety disorder. Although both SCAS-C and SCAS-P total scores achieved moderate AUC values for identifying loss of separation anxiety disorder, the relatively poor sensitivity at their cut-off scores (.61 and .62, respectively) limits the extent to which they can be considered useful for assessing this outcome.
Recovery from social phobia was identified well by CAIS-P (AUC = .78) with good sensitivity (.78) and acceptable specificity (.71) at a cut-off score of 13. However, both SCAS-P total and social phobia subscales had poor sensitivity (.55 and .56, respec tively) at their respective cut-off scores.
The only measure to achieve an AUC exceeding .70 for iden tifying recovery from generalized anxiety disorder was the CAIS-P (AUC = .76), at a cut-off score of 12. This was associated with acceptable sensitivity (.70) and specificity (.72), suggesting that this measure is useful for identifying recovery from generalized anxiety disorder.
Although child and parent reports on the SCAS physical injury subscale achieved moderate AUC values for identifying recovery from specific phobias, the poor sensitivity (.46 and .48, respec tively) at a cut-off score of 2.5 prevents the conclusion that either accurately identify this outcome. No other measure accurately identified recovery from specific phobias.
Discussion
The parent-report CAIS score successfully identified absence of any anxiety diagnosis as established using the standard adminis tration of the ADIS-C/P, albeit with a low cut-off score. Although no measure was particularly successful at identifying whether children recovered from their primary diagnosis, at least one of the questionnaire measures successfully identified recovery from each of the specific diagnoses considered here (apart from specific phobia). In general parent-report scores tended to be better at
Table 3 Results o f ROC Analyses fo r Measures Achieving Area Under the Curve o f> .70 for Identifying Absence o f All Anxiety Diagnoses and Recovery From Primary Diagnosis, Separation Anxiety Disorder, Social Phobia, Generalized Anxiety Disorder, and Specific Phobia
Outcome Time 2 measure Cut-Off score Sensitivity Specificity AUC
Absence of any anxiety diagnoses SCAS-C 22 .66 .70 .73 SCAS-P 18 .60 .72 .75 CAIS-P 7 .70 .70 .81
Recovery from primary diagnosis CAIS-P 8 .61 .73 .75 Recovery from separation anxiety disorder SCAS-C 28 .61 .70 .71
SCAS-P 24 .62 .73 .77 SCAS-C-SA 6 .76 .73 .80 SCAS-P-SA 7 .70 .71 .82 CAIS-P 12 .72 .71 .79
Recovery from social phobia SCAS-P 21 .55 .72 .70 SCAS-P-SP 6 .56 .74 .74 CAIS-P 13 .78 .71 .78
Recovery from generalized anxiety disorder CAIS-P 12 .70 .72- .76 Recovery from specific phobias SCAS-C-PI 2.5 .46 .77 .73
SCAS-P-PI 2.5 .48 .73 .71
Note. AUC = area under the curve; SCAS-C = Spence Children’s Anxiety Scale (child report); SCAS-P = Spence Children’s Anxiety Scale (parent report); CAIS-P = Child Anxiety Impact Scale (parent report); SCAS-C-SA = SCAS separation anxiety subscale (child report); SCAS-P-SA = SCAS separation anxiety subscale (parent report); SCAS-P-SP = SCAS social phobia subscale (parent report); SCAS-C-PI = SCAS physical injury fears subscale (child report); SCAS-P-PI = SCAS physical injury fears subscale (parent report).
840 EVANS, THIRLWALL, COOPER, AND CRESWELL
identifying diagnostic outcomes from the ADIS-C/P than child scores, with the CAIS-P performing best.
There is a paucity of research using ROC methods to evaluate self-report measures as indices of diagnostic outcomes, limiting com parison with other findings. The superior AUC, sensitivity, and spec ificity values found for the PARS at identifying recovery according to ADIS-IV-C/P (Caporino et al., 2013) are understandable given that they are both clinician-rated measures. However, the present findings demonstrate that questionnaire measures can be used as acceptable indicators of some ADIS-C/P diagnostic outcomes on the basis of having AUC values of at least 0.70 and acceptable sensitivity and specificity. Specifically, based on the data sets used here, cut off- scores of the CAIS-P and separation anxiety subscale of the SCAS- C/P can be recommended to assess recovery for children with sepa ration anxiety disorder (CAIS-P < 12; SCAS-C-SA <6; SCAS-P- SA <7), with CAIS-P cut-off scores recommended to assess recovery from social phobia (CAIS-P < 13) and generalized anxiety disorder (CAIS-P < 12). Notably, although the separation anxiety subscale of the SCAS-C/P performed well at identifying recovery from separation anxiety disorder, the social phobia subscale of the SCAS-C/P was not a good indicator of recovery from social phobia and nor was the generalized anxiety subscale a good indicator of recovery from gen eralized anxiety disorder. Furthermore, neither the SCAS-C/P (total or physical injury subscale) nor the CAIS-C/P was accurate at identify ing recovery from specific phobias. This may well be accounted for by the fact that impairment relates to restricted fear domains and contexts and more closely tailored measures may be required, which is also likely to account for the relatively low internal consistency of the SCAS specific phobia scale.
The superior performance of the CAIS over the SCAS for the majority of outcomes may well reflect the fact that meeting diagnostic criteria is dependent on there being significant functional impairment (APA, 1994,2013). It is also important to note that the CAIS-P cut-off point for identifying children with no anxiety diagnoses (i.e., complete recovery) was markedly lower than those for the individual anxiety diagnoses. This is likely to reflect the high comorbidity of anxiety disorders in children (Waite & Creswell, 2014), meaning that a child who has recovered from their primary or any specific diagnosis may well retain at least one other anxiety diagnosis.
Parent reports were generally better at identifying diagnostic out comes on the ADIS-C/P than children’s self-reports: consistent with previous findings of superior accuracy of mother rather than child report as screening tools for child anxiety (Villabp et al., 2012). This may potentially relate to limitations associated with children’s reflec tive abilities, recognition of the broader interference (e.g., to family life) of their symptoms, and/or to anxious children’s tendency to ‘fake good’ (Kendall & Chansky, 1991). Although we restricted our anal yses to a relatively narrow age group (7-12 years), it is likely that the utility of child report will vary substantially within this age group. We would also anticipate that quite different rates of diagnostic accuracy would be found with older populations (i.e., adolescents) and future studies are required with this age group. It is also the case that the superiority of parent report may reflect the fact that because this was a referred sample parents will have been aware of their child’s symptoms and the associated functional impairments. Whether simi lar findings would be found in a longitudinal community study remains unclear".
A further possibility is that the greater agreement between parent (compared with child) report questionnaire scores and diagnostic
outcomes reflected the tendency for poor parent-child agreement on the ADIS (Choudhury, Pimentel, & Kendall, 2003; Comer & Kendall. 2004; Grills & Ollendick, 2003) and for diagnostic outcomes of the ADIS interviews to be more closely related to parent reports (Grills & Ollendick, 2003). We used the standard administration of the ADIS- IV-C/P, that is, diagnoses were given if either parent or child report met diagnostic criteria. As highlighted by existing literature (e.g.. Grills & Ollendick, 2003; Hawley & Weisz, 2003) it is possible, or indeed likely, that the stronger performance of parent reports on questionnaires in predicting recovery in the present study reflects a tendency for final ADIS-C/P diagnoses to reflect parent reports to a greater extent than child reports. In the present study, children and parents showed moderate agreement (62% to 81% across diagnoses) although final clinician-awarded ADIS-IV-C/P diagnoses did more closely reflect parent reports (87% to 92% across diagnoses) than child reports (68% to 86% across diagnoses). This is not to say that child reports are unimportant in assessing recovery from anxiety disorders, and the results of the present study should be considered in the context of the greater parental influence on ADIS-IV-C/P out comes when administered in its standard form with preadolescent children. Further research would benefit from the addition of more objective assessments of recovery from child anxiety disorders which are independent of child and parent reports (e.g., using behavioral observations).
A number of study limitations need to be highlighted. Despite the fact that we used established measures where good psycho metric properties have previously been established, there was considerable variance in internal consistency of measures. The poor internal consistency of the physical injury subscale of the SCAS-C/P further supports our conclusion that it is not a suitable measure of recovery from specific phobias, and is likely to reflect the fact that it is comprised of items regarding discrete fears (e.g., dogs, heights). The CAIS-C also showed poor internal consistency at Time 1, although not at Time 2, and it is unclear why this was found. Nevertheless, most of the Time 2 measures that performed well in terms of identifying recovery from anxiety diagnoses also showed good to excellent internal consistency. The one exception was the separation anxiety subscale of the SCAS-P, which showed poor internal consistency despite comparing favorably with other measures in its accuracy at identifying recovery from separation anxiety disorder.
This was a relatively high socioeconomic group, predominantly of nonminority ethnicity, with children from a limited age range (7-12 years). The study also reports on the ADIS-IV-C/P which assesses DSM-IV diagnoses, although notably there have been few changes in relation to the particular diagnoses covered here in DSM-5.
These limitations notwithstanding, the current study provides evidence to support the use of the parent-report CAIS question naire as a valid tool to assess recovery from childhood anxiety disorders generally and from separation anxiety disorder, social phobia, and generalized anxiety disorder, specifically in 7- to 12-year-old children. Furthermore, the SCAS separation anxiety subscale child and parent reports were able to accurately identify the absence of childhood separation anxiety disorder. These find ings are likely to be of value for monitoring outcomes and guiding decision making in routine clinical practice where full diagnostic interviews may not be feasible.
RECOVERY FROM CHILD ANXIETY DISORDERS 841
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RECOVERY FROM CHILD ANXIETY DISORDERS 843
Appendix
AUC Values for Those Who Received Treatment and for the Overall Sample for Each Diagnostic Outcome at Time 2
Outcome at Time 2 Measure T reated
(n = 274)
AUC
Overall (n = 337)
Absence of any anxiety diagnosis SCAS-C .74 .73 SCAS-P .76 .75 CAIS-C .68 .69 CAIS-P .80 .81
Recovery from primary diagnosis SCAS-C .67 .67 SCAS-P .70 .68 CAIS-C .64 .64 CAIS-P .74 .75
Recovery from separation anxiety disorder SCAS-C .69 .71 SCAS-P .77 .77 SCAS-C-SA .79 .80 SCAS-P-SA .80 .82 CAIS-C .62 .64 CAIS-P .77 .79
Recovery from social phobia SCAS-C .64 .66 SCAS-P .69 .70 SCAS-C-SP .63 .64 SCAS-P-SP .72 .74 CAIS-C .63 .64 CAIS-P .77 .78
Recovery from generalized anxiety disorder SCAS-C .63 .64 SCAS-P .66 .63 SCAS-C-GA .65 .64 SCAS-P-GA .62 .63 CAIS-C .66 .66 CAIS-P .73 .76
Recovery from specific phobias SCAS-C .60 .59 SCAS-P .64 .65 SCAS-C-PI .70 .73 SCAS-P-PI .72 .71 CAIS-C .57 .56 CAIS-P .58 .58
Note. AUC = area under the curve; SCAS-C = Spence Children’s Anxiety Scale (child report); SCAS-P = Spence Children's Anxiety Scale (parent report); CAIS-C = Child Anxiety Impact Scale (child report); CAIS-P = Child Anxiety Impact Scale (parent report); SCAS-C-SA = SCAS separation anxiety subscale (child report); SCAS-P-SA = SCAS separation anxiety subscale (parent report); SCAS-C-SP = SCAS social phobia subscale (child report); SCAS-P-SP = SCAS social phobia subscale (parent report); SCAS-C-GA = SCAS generalized anxiety subscale (child report); SCAS- P-GA = SCAS generalized anxiety subscale (parent report); SCAS-C-PI = SCAS physical injury fears subscale (child report); SCAS-P-PI = SCAS physical injury fears subscale (parent report).
Received December 11, 2015 Revision received June 29, 2016
Accepted June 30, 2016 ■
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J Altern Med Res 2016;8(4):421-429 ISSN: 1939-5868 © 2016 Nova Science Publishers, Inc.
A review on anxiety disorders in children and adolescents
Lauren Boydston, MD, William P French, MD, and Christopher K Varley, MD Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, USA
Correspondence: Lauren Boydston, Department of Child
Psychiatry, OA.5.154, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, United States. E-mail: [email protected]
Abstract
Anxiety disorders are common in children and adolescents and can be quite distressing and impairing for the youth and the family. Fortunately, effective treatments are available. This review will describe common pediatric anxiety disorders and techniques for evaluation and treatment. Anxiety disorders are common in children and adolescents. While some problems with anxiety are developmentally appropriate or mild and will resolve on their own, for some youth anxiety can lead to significant impairment in childhood and may portend a life-long struggle- not only with anxiety but with other mental health problems as well. For this reason, it is important to screen for anxiety disorders whenever a child presents with a behavioral or mental-health related complaint, or when anxiety is suspected to be contributing to a physical complaint, and begin treatment when appropriate. There is excellent evidence to support the use of cognitive behavioral therapy (CBT) in pediatric anxiety disorders. When CBT is not adequate or when impairment is severe, the combination of medication and therapy may be indicated. Although use is off-label in non-OCD anxiety, there is a solid base of clinical experience and empirical support for the safe and effective use of selective serotonin reuptake inhibitors (SSRIs). Because the response is often robust, treatment of pediatric anxiety disorders can be quite satisfying for the child, family and providers. Additionally, the child and family may develop strategies for anxiety management that benefit them for years to come. Keywords: Psychiatry, anxiety disorder, child health, adolescent health, public health
Introduction
Fear and anxiety are normal, and often adaptive, emotional responses to a real or perceived threat. Various worries are typical for children at certain developmental periods (1-3). For example, infants in their first year of life will begin to express anxiety over separation from their primary caregivers, young children often fear the dark and “monsters,” and adolescents commonly express high levels of concern
Lauren Boydston, William P French, and Christopher K Varley 422
about how they are perceived by their peers. For many youth, however, the physical, cognitive and behavioral manifestations of these worries become excessive in terms of intensity or persistence beyond the typical developmental stage (1-3). When these symptoms become overly distressing and/or impairing to the child, evaluation for an anxiety disorder is indicated. Often, the youth is not able to recognize that his or her worries are excessive or unreasonable, and may therefore present to a primarily care provider with a chief complaint of behavioral problems, physical concerns or academic problems, rather than anxiety (1-3).
Definitions
An overview of the clinical features of anxiety disorders seen in children and adolescents is presented below. Specific criteria for diagnoses are described in detail in the “Diagnostic and statistical manual, 5th edition (DSM-5)” (4). All anxiety disorder diagnoses require the symptoms to be “clinically significant” in terms of the amount of distress or impairment experienced. It is important to note that anxiety disorders are often co-morbid with one another and that, as the child ages, evolving symptom presentations may lead to changes in the specific anxiety diagnosis (1, 2).
Separation anxiety disorder (SAD). Some degree of separation anxiety is normal in infants, and increases in symptoms of separation anxiety may occur transiently with certain events such as starting preschool or kindergarten (1). For children with SAD, the fear of separating from attachment figures is developmentally inappropriate or excessive for the child’s age, and must be present for at least 4 weeks (4). A child may avoid age-appropriate activities such as school and sleep-overs. Youth with SAD are likely to express significant distress when they anticipate a separation from home or caregivers. They may worry about events happening that could lead to separation (such as getting lost or kidnapped) or fear that something bad might happen to the caregiver when they are not together (4). As a result, children and adolescents with SAD may be reluctant- or simply refuse- to go anywhere without major attachment figures present. Some children may not want to leave
home at all. School refusal is common (2). Nightmares about separation and physical complaints such as headaches and upset stomach may also occur. Caregivers of youth with SAD may experience significant distress as well due to behaviors such as a child’s refusal to fall asleep without the parent present, resistance to be cared for by a babysitter, or excessive “clinginess” (4).
Selective mutism. A child with selective mutism refuses to talk in certain situations (4). For example, a child may remain silent throughout the school day but talk normally at home; or, a child may speak to peers and caregivers, but not to other adults. The behavior must go on for at least a month and not be better accounted for by a communication disorder or other disorder in which communication is a significant problem, such as autism (4). A child with selective mutism may be able to use non-verbal communication or written communication to get his or her needs met. Comorbid social anxiety is common (1, 4).
Specific phobia. Specific phobias involve anxiety limited to a particular object or situation, lasting 6 months or more (4). Examples of “phobic stimuli” include spiders, dogs, storms, needles, airplanes, enclosed spaces and heights. Exposure to the trigger causes intense distress, or the youth manages to avoid it altogether (4). Some phobias develop after a specific triggering event, for example intense fear and avoidance of solid food after the child experiences a choking episode. Children may express their fear in an “externalizing manner,” for example, by crying or having a tantrum, or they may freeze or cling to a caregiver (4). Fears that are culturally or developmentally normative, or that are realistic for the situation (e.g., going outside at night in a dangerous neighborhood), would not be considered phobias. Before diagnosing a specific phobia, it is important to consider whether the symptoms in question are actually part of another mental disorder such as agoraphobia, obsessive compulsive disorder, social anxiety disorder, an eating disorder, or post- traumatic stress disorder (4).
Social anxiety disorder (social phobia). Known by both terms, the core feature is anxiety about social situations. The youth fears being scrutinized, and may think that he or she will do something embarrassing, inadvertently offend someone, be rejected or judged, or act in a way that reveals his or her anxiety (4). The
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youth experiences intense distress during social situations and may do his or her best to avoid them whenever possible (4). As with other anxiety disorders, the response observed by others may be disruptive behavior, or the youth may “freeze” (4). Examples of feared situations can vary from what may seem to be relatively benign social interactions- such as ordering a drink at a coffee bar or initiating a conversation with a classmate– to more intensive performance situations. To make the diagnosis, the symptoms must be present for at least 6 months (4). The presence of significant distress and impact on social or academic functioning help distinguish social anxiety disorder from shyness, which is not considered pathological (1,4). A distinction of “performance only type” is made if the anxiety only occurs when the individual is speaking or performing in public (4).
Panic attacks, panic disorder, and agoraphobia. A panic attack involves a sudden sense of fear and/or physical discomfort that reaches peak intensity within minutes. To diagnose a panic attack, 4 of 13 specific symptoms must occur, some of which may be physical (e.g., palpitations, sweating, feeling short of breath) and some of which may be cognitive (e.g., feeling as though things are unreal or that one has become detached from oneself) (4). A panic attack can occur during a time of high anxiety or during a calm state and can be “expected” (that is, there is a clear trigger) or “unexpected” (4). Thus, some panic attacks may seem to come completely “out of the blue,” and some sufferers can wake from sleep in a state of panic (1, 2, 4). To meet criteria for panic disorder, at least one of the following conditions must be present: (a) there must be ongoing concern that panic attacks will recur or that they signal something “bad,” such as a heart attack; or, (b) the panic attacks have led to a change in behavior, such as avoidance of certain situations due to fears that they could trigger another attack (4). Frequency of panic attacks can vary widely. A youth can experience panic attacks without meeting criteria for panic disorder, and the DSM-5 allows for a panic attack specifier to be attached to any mental disorder (e.g., generalized anxiety disorder with panic attacks, or major depressive disorder with panic attacks) (4).
In the “Diagnostic and statistical manual, 4th edition (DSM-IV)” (5), agoraphobia was only able to
be diagnosed when it occurred in the presence of panic disorder. The DSM 5 (4), however, allows agoraphobia to be listed as a separate anxiety disorder diagnosis. Youth with agoraphobia must have significant anxiety related to at least two situations such as use of public transportation, being in open or enclosed spaces, being in a line or crowd, or simply being outside of the home (4). It may be that the youth is worried he or she cannot escape or that he or she will have a panic attack (4). As with separation anxiety, the youth may resist going to school or leaving the home at all; the two diagnoses can be distinguished by the feared outcome (e.g., harm coming to a caregiver in the case of SAD versus embarrassing physical symptoms in the case of agoraphobia) (4).
Generalized anxiety disorder (GAD). The hallmark of GAD is the presence of excessive anxiety and worry that is difficult to control, occurring more days than not, and lasting for at least 6 months (4). In addition, a child experiences at least one additional symptom such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and/or sleep problems (4). As with other anxiety disorders, it is not uncommon for youth with GAD to complain of other somatic symptoms, such as frequent headaches or stomachaches (2-4). Unlike other anxiety disorders in which the focus of the worry is often quite consistent, with GAD the youth is likely to have a variety of worries, and the predominant concern may shift from one thing to the next (e.g., grades, having done something wrong, their own or others’ health) (1-4). Children with GAD may frequently seek reassurance, constantly redo tasks, and can develop patterns of avoidance and withdrawal from age- appropriate activities (1-4).
Other diagnoses involving anxiety. The diagnosis unspecified anxiety disorder can be given to children and adolescents for whom it is not yet clear which specific anxiety disorder best applies (4). For children and adolescents who struggle with significantly impairing and/or distressing levels of anxiety, but who do not meet criteria for one of the specific anxiety disorders listed above, a diagnosis of other specified anxiety disorder can be given with an explanation of why the youth does not meet criteria for a more specific diagnosis (e.g., “selective mutism occurring for less than a month” or “recurrent panic
Lauren Boydston, William P French, and Christopher K Varley 424
attacks limited to only 3 symptoms”) (4). When the anxiety is a direct result of a substance or medical disorder, the diagnosis “substance/medication- induced anxiety disorder” or “anxiety disorder due to another medical condition” is given (4).
Anxiety is also a key feature of several disorders that are not classified in the “anxiety disorders” chapter of the DSM-5 (4). These disorders are considered separately because of differences in etiology, core features, course, and/or appropriate treatment. Adjustment disorder with anxiety, acute stress disorder, and post-traumatic stress disorder (PTSD) can all result in significant anxiety symptoms; however, in these cases the development of symptoms is directly related to a specific traumatic or stressful event (4). Youth with obsessive compulsive disorder (OCD) and related disorders, such as trichotillomania, may also experience significant worry and anxiety, and there is significant overlap between the above- described childhood anxiety disorders and OCD- related disorder in terms of treatment (4).
Epidemiology
The prevalence of pediatric anxiety disorders has been estimated to be between 4% and 20% (1-2,6-8), and it is thought that most adult anxiety disorders have their onset in childhood. In the National Comorbidity Study-Adolescent Supplement (NCS-A) of over 10,000 youth aged 13-18, anxiety disorders were the most common mental health disorders endorsed (9). Thirty-two percent (32%) of adolescents reported having met criteria for at least one anxiety disorder in his or her lifetime, and 8% reported having experienced “severe impairment” from anxiety symptoms. Specifically, 19% of youth endorsed having had a specific phobia, 9% social phobia, 8% SAD, 5% PTSD, 2% panic disorder, 2% GAD, and 2% agoraphobia. In the NCS-A, half of the youth had developed their anxiety disorder by age 6, with prevalence rates leveling off at about the age of 12. Unfortunately, less than one-in-five of these youth had received any mental health services for his or her anxiety (10).
The prevalence of some disorders, such as SAD, decreases in frequency over time (4). Panic disorder, on the other hand, is rare in children and gradually
increases in frequency during adolescence (1). Whereas rates of anxiety disorders are similar in younger boys and girls, they become more common in females by adolescence and into adulthood (11).
Genetics and environmental factors both appear to play important roles in the development of pediatric anxiety disorders. Having a biological relative, particularly a parent, with significant anxiety increases the child’s risk (1-2, 4). A temperament characterized by behavioral inhibition- a tendency to avoid things that are new- may predispose a child to development of an anxiety disorder later in life (1-4). Symptoms of an anxiety disorder may start out subclinical with the child tending to worry more or seem more cautious than other children, but without significant distress or functional impairment. Furthermore, anxious caregivers may model anxious coping and unintentionally reinforce behaviors that maintain anxiety, such as avoidance of fear-inducing situations (1). Some anxiety disorders develop following stressful events such as a loss of a loved one or parental divorce (4).
For some children, their anxiety disorder will remit completely (1, 2, 11). For others, the severity of anxiety can wax and wane over time, and the focus of the anxiety may shift as the youth transitions from child to adolescent to adult (1, 2, 11). An individual can struggle with different anxiety disorders at difference times in life (1, 2), for example, meeting criteria for SAD in childhood, social phobia in adolescence, and then developing GAD in adulthood. In addition to the development of new anxiety disorders, children with anxiety are also at increased risk of developing depression (1, 2, 11).
Clinical features
Core DSM 5 criteria and associated clinical features of specific anxiety disorders are described above. As previously stated, knowledge of developmentally- appropriate fears and worries is important in the assessment of anxiety. Anxiety disorders are distinguished from normal worries by the severity and functional impairment or by the inappropriateness for developmental stage (3, 4). Comorbidity between anxiety disorders is common; for example, SAD and GAD often co-occur (2, 4, 11). Comorbidities with
Anxiety disorders 425
other classes of psychiatric disorders are common as well. Youth may also experience clinically significant depression, ADHD, and oppositional defiant disorder (ODD) (1, 2). Providers should be aware that while oppositional behaviors may seem to represent a separate clinical problem, they may in fact be a direct result of the anxiety itself (4). A child may appear non-compliant as he or she attempts to avoid anxiety- inducing situations and may become behaviorally dysregulated as a result of autonomic arousal. Adolescents with anxiety are also at risk of the development of a substance use disorder, including alcohol abuse (1, 2, 11). Although rare in children and adolescents, youth with anxiety should be screened for signs and symptoms of a bipolar spectrum disorder, particularly when medications are being considered.
Diagnosis
The “American Academy of Child and Adolescent Psychiatry” recommends routinely screening for anxiety in any initial mental health assessment (1). Indeed, knowing that anxiety is the most common psychiatric disorder in youth, and knowing that anxiety can present with externalizing behaviors, such as tantrums, it is prudent to consider anxiety any time there is a psychiatric or behavioral chief complaint.
Information should be gathered from both the child and collateral informants (1, 2). Youth typically have the best sense of what is going on internally (1). Adolescents are likely to be able to describe the nature, severity, intensity of their anxiety and associated thoughts and feelings with direct questioning. For young children who have difficulty expressing their internal experiences, strategies such as use of play or drawings, and/or a “feelings thermometer” may be helpful (1, 3). Caregivers and teachers, on the other hand, may be more likely than the child to accurately report any behavioral problems and to describe the functional impact of the anxiety on the child’s life (1). Given that comorbidity is common, providers should also screen for symptoms of other common pediatric mental health problems including depression, attentional problems, and disruptive behavior. Providers should ask about the use of prescription and over the counter medications,
supplements, caffeinated and other energy drinks, and other substances. Questions should also be asked regarding possible precipitating factors, including traumatic events and peer-related problems such as bullying.
Self- and parent-report rating scales can be very helpful in supplementing the clinical interview, as they allow providers to compare a youth’s symptoms to those of a broader population (1). Additionally, some individuals may report symptoms on a checklist that they forgot or did not feel comfortable reporting during the interview. There are multiple “broadband” rating scales available that can be used to screen for multiple types of mental health issues. The “Child behavior checklist” (CBCL), for example, is a well- known and commonly used broadband rating scale that assesses symptoms in multiple domains; it has parent, youth and teacher versions that can be used together to get a more thorough sense of the child’s symptomatology and impairment (12). The “Pediatric symptoms checklist-17” (PSC-17) screens for the general categories of “internalizing,” “attention” and “externalizing” symptoms (13). In addition to a broadband rating scale, the use of an anxiety-specific rating scale is recommended. The “Screen for child anxiety related emotional disorders” (SCARED), for example, divides anxiety symptoms into various categories that can help delineate specific DSM diagnoses (e.g., panic symptoms or separation symptoms) (14). The SCARED is available in both child and parent versions.
A complete review of systems is recommended to screen for possible medical problems that could be contributing to the anxiety and to document the child’s baseline somatic symptoms (1). Because anxiety symptoms can be caused by medical conditions and substances, it is also recommended that the child have a thorough physical examination (11). Laboratory tests such as urine drug screen, thyroid studies, and electrolytes should be considered. Other studies may also be considered based on the nature of the child’s physical complaints, e.g., an EKG or Holter monitor for cardiac complaints, a sleep study for ongoing sleep disturbance, or an EEG for symptoms concerning for seizures (2, 11). It is important to note, however, that children with anxiety disorders may be more prone to somatic complaints and have greater difficulty being reassured, which
Lauren Boydston, William P French, and Christopher K Varley 426
could contribute to a cycle of unnecessary tests and procedures in an attempt to find a “cause.” Good clinical judgment, therefore, is essential.
Other medical and psychiatric causes of symptoms should be considered. Medical conditions that can cause anxiety, or mimic some of the features of various anxiety disorders, include hyperthyroidism, hyperparathyroidism, and other endocrine disorders; seizures, central nervous system lesions, migraines and other neurologic conditions; lead poisoning; and asthma (1, 4, 11). Potential substances that can contribute to symptoms of anxiety include medications such as steroids, antiasthmatic med- ication, antipsychotics, antidepressants, anti- histamines, and psychostimulants; drugs of abuse such as methamphetamine, cocaine and even marijuana; caffeine and energy drinks; and withdrawal from agents such as alcohol or benzodiazepines (1, 4, 11). Again, decisions about potential medical investigations should be made in a thoughtful manner to avoid unnecessary and potential harmful interventions.
Other psychiatric conditions have symptoms that overlap with those of the anxiety disorders but should be considered separately, as they may require a much different course of treatment. As noted above, anxious children can appear to have externalizing disorders (e.g., tantrums or disobedience) in their attempt to avoid anxiety-provoking situations; however, for some children these types of behaviors may be unrelated to anxiety and constitute a separate disorder. Core symptoms of autism spectrum disorders, such as the insistence of sameness and ritualized patterns of behavior, can also be confused with anxiety (1, 4). Additionally, the social impairments of youth with higher-functioning autism can be difficult to distinguish from social anxiety; and because the distinction can be subtle, evaluation by a specialist may be necessary. In adolescents, early onset psychosis is a rare cause of anxiety-like symptoms (1, 4). Substance abuse, however, is much more common and should be considered (1, 4, 11).
Treatment
Research has shown that there are effective and generally well-tolerated treatments for childhood
anxiety disorders, most notably cognitive behavior therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) (1-3, 6, 11). Some youth will respond well to basic interventions; however, for many treatment will need to be multimodal and involve coordination between youth, parents, school, primary care providers, and mental health specialists (1).
Education about the nature of anxiety should always be a part of treatment and may need to be ongoing (3). Understanding that anxiety is a normal, adaptive process; learning about the physiological cause of fear and anxiety symptoms; and review of the causes and maintaining factors of anxiety disorders (both in general and for the particular child in question) are important first steps in learning to manage anxiety. How much information to provide the child will of course depend on his or her developmental level.
Psychotherapy. In cases of anxiety that are mild, yet causing some degree of impairment or distress, a psychotherapy-only approach is typically recommended (1). Multiple randomized controlled trials support the efficacy of CBT for anxiety (1, 2, 6, 11). The cognitive (thinking) component of CBT involves teaching children skills to see the association between their thoughts, emotions and behaviors and to challenge their anxious and negative thoughts (1-3, 6). The behavioral component of CBT involves teaching the child and/or parents relaxation skills, imagery, and breathing exercises, and the use of exposure (1-3, 6). Exposure may include the building of a “fear hierarchy,” which is used to gradually confront anxiety-provoking stimuli without being allowed to engage in escape behaviors. The positive reinforcement of progress helps increase the likelihood of success (1). For young children, or children with developmental disabilities, treatment will likely entail utilizing more behavioral than cognitive techniques (6). The younger the child, the more heavily parents will need to be involved in the therapy as they will need to help their child practice new skills between sessions and model good anxiety- management skills themselves. There are several CBT manuals for use with youth and adolescents, and for older and/or more cognitively advanced adolescents, manuals meant for adults may also be appropriate. Some adolescents and parents may be able to use self-
Anxiety disorders 427
guided CBT manuals and techniques with good results (1).
Psychodynamic psychotherapy has also been used for decades for the treatment of pediatric anxiety, although there are very few clinical trials testing its efficacy (1). Similarly, there is little empirical evidence for family therapy as a primary treatment for pediatric anxiety disorders (1). In family therapy, the family’s structure and/or patterns of interaction are the “patient,” rather than one identified individual family member. For some families of anxious children with complicated interpersonal dynamics, combining family therapy with individual CBT for one (or more) family member may be indicated (1).
Classroom interventions for anxious youth may include accommodations, such as more time for assignments or tests and additional support from adults. These accommodations can be written into a 504 or Individualized Education Program (IEP) (1). It is important, however, to be mindful of the possibility of inadvertently reinforcing anxiety by allowing the child to avoid anxiety provoking situations. For example, the ability to do school online at home may be very appealing to some youth with severe anxiety but risks further social isolation and entrenchment of their disorder.
Pharmacotherapy. Medication is considered in cases of moderate to severe anxiety, particularly when there has been no or limited response to psychotherapy, when psychotherapy is not available, or when there is a comorbid problem that is likely to be medication-responsive (1). Studies have supported the efficacy, compared to placebo, of several SSRIs including fluoxetine, fluvoxamine, sertraline, and paroxetine (1, 8, 11). Although none of the SSRIs are US Food and Drug Administration (FDA) approved for the use in non-OCD pediatric anxiety disorders, they are generally considered first-line when medications are used, given the empirical evidence in adults and vast clinical experience (1, 3, 11). There are no studies comparing one SSRI to the other, thus factors in choosing which one to use often include physician and family experience with a particular medication, comorbid diagnoses, and side effect profile (1, 3, 11). Other factors to consider include the FDA approval of the use of fluoxetine, sertraline and fluvoxamine for children with OCD, and the FDA
warning issued in 2003 against the use of paroxetine in youth with depression (11).
There is also some evidence supporting the “off label” (i.e., not FDA-approved) use of other medications in pediatric anxiety, such as the selective serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (8,11). Venlafaxine, however, is generally not used as a first or second choice due to a higher side effect profile (11). Studies comparing tricyclic antidepressants, such as clomipramine or imipramine, in non-OCD anxiety have not been uniformly positive, and because of the potential side effects and risk in overdose compared to SSRIs, they are infrequently used (1, 2, 11). Data have not supported the use of benzodiazepines in pediatric anxiety, and they carry the possibility of sedation, tolerance, dependence, and adverse effects on learning and memory (1, 11). Thus, they are recommended only for short-term use in severe cases (1, 3, 11), and ideally, on a scheduled rather than as needed basis.
Kodish, and colleagues, proposed an algorithm for medication management of pediatric anxiety based on a review of the available evidence (11). They suggested starting with an SSRI and titrating the dose every 2-4 weeks until there was good response, intolerable side effects, or maximum dose had been reached. If not successful, the next recommended step is to try a second SSRI, followed by venlafaxine. Next, providers could consider buspirone or mirtazapine, either as monotherapy or as augmentation of an SSRI. The use of benzodiazepines was recommended only if necessary for acute symptoms or if all other medication trials were unsuccessful. Table 1 lists the typical starting doses and therapeutic ranges of several medications used for pediatric anxiety.
Common side effects of SSRIs, such as headaches, nausea and stomachaches, may improve with time (1, 3, 8, 11). These types of symptoms may also occur as a result of the underlying anxiety, so it is important to have a baseline understanding of the child’s somatic symptoms. Antidepressants can be activating in some children, so providers should monitor for increased agitation, restlessness, irritability, problems sleeping, worsening anxiety, and/or other behavioral changes (1, 3, 11).
Lauren Boydston, William P French, and Christopher K Varley 428
Table 1. Select medications used in the management of pediatric anxiety
Medication Starting daily dose Typical therapeutic range Fluoxetine 5-10 mg 10-60 mg Sertraline 12.5-25 mg 50-200 mg Paroxetine 5-10 mg 10-40 mg Fluvoxamine 12.5-25 mg 100-300 mg divided b.i.d. Citalopram 5-10 mg 10-40 mg Escitalopram 2.5-5 mg 5-20 mg Venlafaxine XR 37.5 mg 75-225 mg Buspirone 5 mg (b.i.d. or t.i.d) 15-60 mg (divided b.i.d or t.i.d) Mirtazapine 7.5-15 mg 7.5-30 mg (typically qhs) Clonazepam 0.25 mg -0.5 mg (q.d.or b.i.d.) 0.25 mg to 3 mg (divided q.d. to t.i.d) Lorazepam 0.5-1mg 0.5-6 mg (divided q.i.d)
*Not FDA-approved. Sources 1,3,11.
Activation from an SSRI should not be confused
with a substance-induced manic or hypomanic episode, which is possible with all antidepressants but fortunately very rare (1, 3, 11). If considering medications other than SSRIs, be aware of notable side effects such as the potential for venlafaxine to increase blood pressure and for mirtazapine to cause weight gain (11). Since 2004, all medications marketed as antidepressants, including all SSRIs, have been labeled with a “black box warning” about the possible emergence of suicidal thoughts and behaviors (1, 3, 11). This warning emerged from retrospective analysis of studies of youth with depression. In their 2009 review of antidepressant trials for pediatric anxiety, Ipser and colleagues found that only 13 of the 2,519 patients studied experienced suicidal ideation, and there were no completed suicides (8). When medications are effective, consideration should be given at some point to discontinuation to determine if the medication is still necessary for the child (1). Pine recommends considering a trial off medication after 1 year of improvement, ideally during a low-stress period, such as during summer vacation (15). Given the possibility of withdrawal symptoms and potential increased risk of relapse if stopped abruptly, a gradual taper is recommended (3, 15).
Combination treatment. For children with moderate to severe anxiety, a combination of medication and psychotherapy is recommended (1, 11). If the youth is initially treated with CBT or medication alone without sufficient benefit, then it is
recommended that the other component be added to the treatment plan (1, 11). The “Child-adolescent anxiety multimodal study” compared the use of CBT, sertraline, a combination of CBT and sertraline, and a placebo pill in almost 500 youth ages 7 to 17 with SAD, GAD or social phobia (7). After 12 weeks, they found that 80% of youth who received combination treatment were “much or very much improved,” compared with 60% who received CBT without medication, 55% who received medication without CBT, and 24% who received placebo.
Conclusion
Anxiety disorders are common in children and adolescents. While some problems with anxiety are developmentally appropriate or mild and will resolve on their own, for some youth anxiety can lead to significant impairment in childhood and may portend a life-long struggle- not only with anxiety but with other mental health problems as well. For this reason, it is important to screen for anxiety disorders whenever a child presents with a behavioral or mental-health related complaint, or when anxiety is suspected to be contributing to a physical complaint, and begin treatment when appropriate. There is excellent evidence to support the use of cognitive behavioral therapy (CBT) in pediatric anxiety disorders. When CBT is not adequate or when impairment is severe, the combination of medication
Anxiety disorders 429
and therapy may be indicated. Although use is off- label in non-OCD anxiety, there is a solid base of clinical experience and empirical support for the safe and effective use of selective serotonin reuptake inhibitors (SSRIs). Because the response is often robust, treatment of pediatric anxiety disorders can be quite satisfying for the child, family and providers. Additionally, the child and family may develop strategies for anxiety management that benefit them for years to come.
References
[1] Connolly SD, Bernstein GA, Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2007;46:267-83.
[2] Krain AL, Ghaffari M, Freeman J, Garcia A, Leonard H, Pine DS. Anxiety disorders. In: Martin A, Volkmar FR, eds. Lewis’s child and adolescent psychiatry: A comprehensive textbook, 4th ed. Philadephia, PA: Wolters Kluwer Health, Lippincott Williams Wilkins, 2007:538-48.
[3] Varley CK, Henry A. Anxiety disorders. In: Greydanus DE, Patel DR, Pratt HD, Calles Jr JL, eds. Behavioral pediatrics, 3rd ed. New York: Nova Science, 2009:239- 53.
[4] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association, 2013.
[5] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association, 2000.
[6] James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2013;6:CD004690.
[7] Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008;359:2753-66.
[8] Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009; 3:CD005170.
[9] Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2010;49:980-9.
[10] Merikangas KR, He JP, Burstein M, Swendsen J, Avenevoli S, Case B, et al. Service utilization for lifetime mental disorders in US adolescents: results of the National Comorbidity Survey- Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2011;50:32-45.
[11] Kodish I, Rockhill C, Ryan S, Varley C. Pharmacotherapy for anxiety disorders in children and adolescents. Pediatr Clin North Am 2011;58:55-72.
[12] Achenbach TM, Ruffle TM. The child behavior checklist and related forms for assessing behavioral / emotional problems and competencies. Pediatr Rev 2000;21:265-71.
[13] Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher KJ. Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. Arch Pediatr Adolesc Med 1999;153:254-60.
[14] Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the screen for child anxiety related emotional disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry 1999;38:1230-6.
[15] Pine DS. Treating children and adolescents with selective serotonin reuptake inhibitors: how long is appropriate? J Child Adolesc Psychopharmacol 2002; 12:189-203.
Submitted: April 07, 2015. Revised: May 08, 2015.
Accepted: May 22, 2015.
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Birth Order and Sibling Gender Ratio of a Clinical Sample
1 Iranian J Psychiatry 10:1, Jan 2015 ijps.tums.ac.ir
Prevalence of Anxiety Disorders among Children and
Adolescents in Iran: A Systematic Review Hadi Zarafshan, MA
1
Mohammad-Reza Mohammadi, MD1 Maryam Salmanian, MSc1
1 Psychiatry and Psychology
Research Center, Tehran University of Medical Sciences, Tehran, Iran. Corresponding author:
Maryam Salmanian, MSC Psychiatry and Psychology Research Center, Roozbeh Hospital, South Kargar Avenue, Tehran, Iran. Tel: +98 21 55413540. Fax: +98 21 55421959. E-mail: m- [email protected]
Objective: We aimed to conduct a review to investigate the prevalence of
anxiety disorders among Iranian children and adolescents. Method: We systematically reviewed the literature up to June 2014. We
searched three Persian databases (Magiran, IranMedex and SID) and three English databases: PubMed, Scopus and PsycINFO. All original studies that investigated the current prevalence of anxiety in a sample of Iranian children and adolescents were entered into the study. All studies conducted on special samples or in special settings were excluded. By searching English databases, we obtained 124 original studies. After removing duplicate papers, 120 articles remained. In the next step, we screened the articles based on their title. In sum, 95 Persian and English articles had relevant titles. After screening based on the abstract and full text, 26 studies remained. After screening based on the full text, all selected studies were qualitatively assessed by two evaluators separately. Result: Twenty five studies were eligible and reported different types of
anxiety disorders (i.e., generalized anxiety, separation anxiety, obsessive- compulsive disorder, phobias and panic disorder). The samples varied from 81 to 2996 among studies and their age range was 5 to 18 years. These studies were conducted in different cities of Iran. SCL-90 is a frequently used questionnaire. All anxiety disorders were mostly investigated with the prevalence rates ranging from 6.8% in Saravan to 85% in Bandar Abbas. OCD was the second common study with prevalence rates ranging from 1% in Tabriz to 11.9% in Gorgan . Conclusion: Our findings revealed considerable amount of anxiety
disorder among Iranian children and adolescents. Given the fact that anxiety disorder has negative effects on the well-being and function of individuals and can lead to severe problems, this disorder should be considered in mental health programs designed for children and adolescents. Keywords: Anxiety, Prevalence, Children, Adolescents, Iran
Anxiety disorders include separation anxiety
disorder, selective mutism, specific phobia, social
phobia, panic disorder, agoraphobia and generalized
anxiety disorder, which are characterized with
excessive fear and anxiety and relative behavioral
disturbances(1). Based on the fourth edition of
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV), obsessive-compulsive disorder
and post-traumatic stress disorder were subsets of
anxiety disorders, which have been brought out from
this category and relocated to their own respective
chapters in the fifth edition of DSM (2).
There are several risk factors for anxiety disorders
such as female gender, lower education, low
socioeconomic situation, familial anxiety disorders,
hypersensitivity of amygdala, introversion
personality in early childhood, behavioral inhibition,
parental psychopathology, high levels of coldness,
protectiveness and authoritarianism in parents and
adverse experiences in childhood and traumatic life
events (2-4) The high personal, social and economic burdens are
associated with anxiety disorders (5); therefore, that
impairment in psychosocial and work functioning,
greater fatigue and sleep disturbance, poorer physical
health, suicide attempts, global cognitive impairment
and social disability were significantly linked to
generalized anxiety disorder (6). Anxiety disorders are the most prevalent mental
disorder among children and adolescents involving
10-20% of this group (7). In a national face-to-face
survey of 10123 American adolescents aged 13 to 18
years, Burstein et al. (2014 & 2011) reported that
around 3% and 9% of the participants had
generalized anxiety disorder in 6 months duration,
and social phobia in their lifetime, respectively (8, 9).
Sharkey & McNicholas (2012) indicated selective
mutism of 0.18% in 10927 urban school children in
Systematic Review
Iran J Psychiatry 2015; 10:1: 1-7
Zarafshan, Mohammadi, Salmanian
Iranian J Psychiatry 10:1, Jan 2015 ijps.tums.ac.ir 2
Republic of Ireland (10). Another research reported
social phobia of 12.7%, agoraphobia of 8.6% and
specific phobia of 7.5% among 6-18 years old
students in Qatar (11). In a research conducted on 6
to 17 year old children and adolescents in Korea,
7.9% specific phobia was reported in one year (12).
In a national cohort study, Esbjørn et al. (2010)
evaluated the prevalence of anxiety disorders among
13241 Danish children and adolescents aged 0–19
years. The results of this study revealed that 0.4%,
0.5%, 1.1%, 1.5% and 2.4% of the participants had
separation anxiety disorder, specific phobia, social
phobia, generalized anxiety disorder and other
anxiety disorders respectively (13). Ranta et al.
(2009) showed a 12-month prevalence of 3.2% for
social phobia in 12–17-year-old Finnish adolescents
(14). Another research reported 4.4% social phobia
in Swedish adolescents (15). Adewuya et al. (2007)
found 2.4%, 2.1%, 3.6%, 2.5%, 1.7%, 0.2%, 4.8%
and 15% for the 12-month prevalence of panic
disorder with or without agoraphobia, separation
anxiety disorder, generalized anxiety disorder,
specific phobia, obsessive–compulsive disorder,
post-traumatic stress disorder, social phobia and all
anxiety disorders among Nigerian adolescents,
respectively (16). In a study conducted on Polish
adolescents, Rabe-Jabłońska et al. (2004) reported
that 17% and 7% of the adolescents had specific and
generalized types of social phobia, respectively (17).
Boyd et al. (2000) indicated that 13.2% of 11-18-
year-old Australian adolescents were anxious (18 .) To our knowledge, no study has investigated the
prevalence of anxiety disorders in children and
adolescents across Iran; only different evaluations
were done on this subject in some cities. For
instance, Jalali & Pourahmadi (2012) assessed
anxiety disorders among 10-14-year-old students in
Gorgan, a city in north of Iran. They reported social
phobia of 10.5%, panic disorder of 12.2%,
generalized anxiety disorder of 12.8%, obsessive-
compulsive disorder of 11.9%, separation anxiety
disorder of 15.7% and fear of physical injury of 18%
(19). Another research conducted on 7-9-year-old
male students in Isfahan indicated 6.93% separation
anxiety disorder (20).
Several studies reported the prevalence of anxiety
disorders in children and adolescents in different
locations of Iran, but there was heterogeneity
between the reported prevalence. Furthermore, due to
the lack of overall review, we conducted a systematic
review on the literature and reported the prevalence
of anxiety disorders among children and adolescents
in Iran.
Material and Methods
We systematically reviewed the literature from 1995
until June 2014. Due to the specificity of the study
subject, we only searched Persian and English
databases. We searched three Persian databases
(Magiran, IranMedex and SID) and three English
databases: PubMed, Scopus and PsycINFO. Our search
terms in English databases were "(incidence OR rate
OR prevalence) AND ("psychiatric disorder" OR
anxiety OR phobia OR panic OR ocd OR "obsessive
compulsive disorder" OR ptsd OR "post-traumatic
stress disorder") AND (child OR adolescent OR
adolescence) AND Iran", and was restricted by "title
and abstract" field. In Persian databases, we used
Persian words that had same meaning with English
terms. Our search was limited to online databases. Inclusion and Exclusion Criteria
Since the main goal of this study was to estimate the
prevalence of anxiety among Iranian children and
adolescents, all original studies that investigated the
current prevalence of anxiety in a sample of Iranian
children and adolescents were entered into the study.
All studies conducted on special samples (e.g., those
who experienced special events such as earthquake) or
in special settings (e.g., those who lived in an
orphanage or dormitory) were excluded from the study . Identification and Screening
By searching English databases, we obtained 124
original studies. After removing duplicate papers, 120
articles remained. In the next step, we screened the
articles based on their title and 37 had relevant titles.
The Persian databases did not have an option to export
search results; we read the list of the search output and
selected the relevant studies based on their title. Fifty
eight Persian articles had relevant titles. In total, 95
Persian and English articles had relevant titles. After
screening based on the abstract and full text, 25 studies
remained (Figure 1).
Quality Assessment
After screening based on the full text, all selected
studies were qualitatively assessed by two evaluators
separately. We used a new instrument that is made by
Giannakopoulos et al. for assessing the quality of
prevalence studies (21). This instrument considers
three main criteria: sampling, measurement and
analysis. No study was excluded due to low quality. Data Extraction
The data (year and area), participants’ characteristics
(total sample, percent of boys, percent of girls and age)
and prevalence of all types of anxiety were extracted
from the included studies. Two researchers extracted
the data based on a previously prepared data extraction
form.
Results
As seen in Table 1, 25 studies were eligible to answer
our study question (the prevalence of anxiety disorder
among Iranian children and adolescents). These studies
reported different types of anxiety disorders (i.e.,
generalized anxiety, separation anxiety, test anxiety,
OCD, PTSD, phobia and panic disorder). The samples
varied from 81 to 2996 among studies with the age
range of 5 to 18 years.
Prevalence of Anxiety Disorders in Iran
Iranian J Psychiatry 10:1, Jan 2015 ijps.tums.ac.ir 3
Table 1: Summary of Included Studies
studies Total (N)
Male (%)
Female (%)
Age (mean or
rang) City or province Instrument/s
Outcome/s (%)
Male (%)
Female (%)
Both (%)
1 Mozafari et al.(34) 199 - - 12-18 Shiraz Childhood Behavioral Checklist (CBCL)
- - Separation anxiety: 0% Specific phobia: 3% Social phobia: 8% Panic disorder: 1% Agoraphobia: 1.2% Generalized anxiety
disorder: 7% OCD: 3.5% PTSD: 1.5%
2 Amirfakhraei & Alinaghizadeh (22)
800 42.5% 57.5% high school students
Bandar Abbas The Symptom Check List-90-Revised (SCL-
90-R)
Anxiety disorder: 29%
Specific phobia: 15%
OCD: 38%
Anxiety disorder: 50%
Specific phobia: 28%
OCD:52%
Anxiety disorder: 85%
3 Lashkaripour et al. (38)
935 42.2% 57.8% Middle School
Students
Zahedan Test Anxiety Questionnaire (TAQ)
Test Anxiety:35.2%
Test Anxiety: 48.3%
Test Anxiety: 42.8%
4 Ghafarinejad (40) 2944 50.9% 49.1% High school Students
Kerman Semi Structured Questionnaire based on
DSM IV
Social Phobia: 10.3%
Social Phobia: 19%
Social Phobia: 14.6%
5 Ahmadi et al. (33) 410 50.7% 49.3% High School Students (17-
18)
Shiraz Beck Anxiety Inventory Anxiety Disorder:44.7%
Anxiety Disorder: 64.5%
Anxiety Disorder: 54.5%
6 Abd-Khodaie & Sadeghi (41)
358 0 100% 5-6 Mashhad The Child Symptom Inventory (CSI)
- Separation Anxiety: 13.97%
7 Nilchian & Mohammadi (39)
583 54.4% 45.6% Elementary School
Students (4th, 5th, 6th Classes)
Shahrekord Modified Child Dental Anxiety Scale Figurated
- - Dental anxiety: 9.34%
8 Qamari-givi et al. (42)
2000 - - Elementary School
Students (5th Class)
Qorveh Screen for Childhood Anxiety Related
Emotional Disorders (SCARED)
Generalized Anxiety: 9.4%
Generalized Anxiety: 11.08%
Generalized Anxiety: 10.07%
9 Narimani (26) 731 - - High School Students
Ardebil Cattell's Anxiety Scale Questionnaire
- - Anxiety Disorder: 24.1%
10 Ranjbar et al. (35) 1092 55.2% 44.8% 5-16 Tabriz Rutter Questionnaire and Evaluation of
Psychiatrist
- - Anxiety Disorder: 6.9% Separation Anxiety:
0.7% Specific Phobia: 1.6% Generalized Anxiety:
0.54% OCD: 1%
11 Nassi et al. (20) 1514 100% 0 7-9 (Elementary
School Students)
Isfahan Separation Anxiety Scale, Children Anxiety
Inventory
Separation Anxiety: 6.93%
- -
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Zarafshan, Mohammadi, Salmanian
Iranian J Psychiatry 10:1, Jan 2015 ijps.tums.ac.ir 4
studies Total (N)
Male (%)
Female (%)
Age (mean or
rang) City or province Instrument/s
Outcome/s (%)
Male (%)
Female (%)
Both (%)
12 Saberi (27) 350 50% 50% Elementary School
Students
Roodehen Childhood Behavioral Checklist (CBCL)
Anxiety Disorder: 12%
Anxiety Disorder: 16%
Anxiety Disorder: 14%
13 Hajiamini et al. (43) 200 28% 72% 6-10 (Elementary
School Students)
Abhar School Anxiety Scale- Teacher Report (SAS-
TR)
Social Phobia: 21.3%
Generalized Anxiety: 20%
Social Phobia: 78.8%
Generalized Anxiety: 80%
Social Phobia: 23.5% Generalized Anxiety:
20%
14 Assarian et al. (36) 293 49.5% 50.5% High School Students
Kashan Yale-Brown Scale OCD: 5.1% OCD: 3.75% OCD: 8.87%
15 Jalali & Pourahmadi (19)
344 Schooler children (10– 14 years old
childen)
Gorgan Spence Child Anxiety Scales (SCAS)
Anxiety Disorder: 7.3%
Anxiety Disorder: 3.5%
OCD:11.9% Anxiety Disorder: 10.8%
Separation Anxiety: 15.7%
18% Fear of Physical Injury (specific Phobia) Social Phobia: 10.5% Panic Disorder: 12.2% Generalized Anxiety:
12.8%
16 Shams et al. (23) 909 39.20% 60.80% 14-18 years Cities of Ardakan and Maybod, a Semi-Rural Area in the Province of Yazd (south- East of
Iran)
the Maudsley Obsessive-Compulsive Inventory (MOCI) & the
Symptoms Checklist -90- revised (SCL-90-R)
OCD: 4.7% OCD: 6.7% OCD: 11.2%
17 Ghoreishi et al. (28) 81 0% 100% 15-18 years Zanjan Zung - Anxiety Disorder: 22.30%
18 Seyd-nozadi (44) 337 53.50% 46.50% 16-20 years Mashhad - - - Severe levels of state and trait anxiety was
seen in 23% and 19%, of students respectively
19 Masud-zadeh (37) 2996 0% 100% 16.22±3.4 Sari Maudsley Obsessive- Compulsive Inventory
(MOCI)
- OCD: 31.2% -
20 Sadeghian (29) 600 0% 100% 16-17 years Hamedan GHQ-28 - Anxiety Disorder: 46.5%
-
21 Kheyrkhah (30) 159 0% 100% 14-16 years Tehran Spiel Berger Anxiety Questionnaire
- Anxiety Disorder: 18.%
Severe & 53.5 % mild
-
22 jena-abadi (24) 117 48.70% 51.30% Saravan SCL-90-R - - Anxiety Disorder: 6.8% Severe
23 Salari (31) 134 61.20% 31.80% 13-19 years Zahedan & Gonabad Cattell's Anxiety Scale Questionnaire
- - Anxiety Disorder: 55.97 Mild & 13.43 Severe
24 Movahhedi-rad (32) 570 0% 100% - Mashhad Spiel Berger Anxiety Questionnaire
- 22.8% Trait Anxiety
-
25 Hosseyni-fard (25) 830 45.42% 55% High-school Rafsanjan SCL-90-R & DSM-IV - - Anxiety Disorder: 8.4%
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Prevalence of Anxiety Disorders in Iran
Iranian J Psychiatry 10:1, Jan 2015 ijps.tums.ac.ir 5
These studies were conducted in different cities of Iran.
Different questionnaires were used in these studies, but
SCL-90 was used most frequently (22-25). All anxiety
disorders were most investigated in 11 studies (22, 24-
33) with prevalence rates ranging from 6.8% in
Saravan (24) to 85% in Bandar Abbas (22). OCD was
the second common study which was evaluated in 5
researches (19, 22, 23, 34-37) with prevalence rates
ranging from 1% in Tabriz (35) to 11.9% in Gorgan
(19). Test anxiety disorder with the prevalence rate of
42.8% in Zahedan (38), and dental anxiety with
prevalence rate of 9.34% in Shahrekord (39) were only
reported in one study (Table 1).
Discussion
Due to the methodological heterogeneity between the
studies, we could not combine or meta-analyze the
results. This review confirms the high prevalence of
anxiety disorders with considerable heterogeneity in
different regions of Iran. Although a review showed a
prevalence rates of 2.6% to 41.2% for any anxiety
disorder in pre-adolescent children (45), our study
reported the prevalence rates of 6.8% to 85% for
anxiety disorders in Iranian children and adolescents
(19, 22, 24-27, 31, 33, 35, 44). Among Iranian
investigations, more frequencies of anxiety disorders
were reported in most studies using the symptom
inventory (22-24, 26, 29, 31, 32, 41, 43). Furthermore,
some cities such as Bandar Abbas had higher rates of
anxiety disorders (22), which need to be considered
and studied .
In this study, the prevalence rates of separation anxiety
disorder were 0.7% to 15.7% among Iranian children
and adolescents (19, 20, 35); which is consistent with
other findings that reported 0.5% to 20.2% for the
prevalence of separation anxiety disorder (45).
The present review showed the prevalence rates of
0.54% to 12.8% for generalized anxiety disorder (19,
35, 42, 43), which nearly confirms the past review that
indicated the prevalence rates of 0.16% to 11.1% (45).
However, one Iranian study conducted in Abhor found
the prevalence of 20% for generalized anxiety disorder
(43), which needs to be investigated .
The prevalence rates of OCD ranging from 1% to
11.9% among Iranian children and adolescents were
higher than other communities which reported the
prevalence rates of 0.03% to 2.6% (19, 23, 34-36, 45);
this inconsistency should be further studied .
Social phobia with prevalence rates of 8% to 23.5%
among Iranian children and adolescents were more
common than four communities reporting the
prevalence rates of 0.08% to 0.9% (19, 34, 40, 43, 45).
However, one study showed the prevalence of 17%
among polish adolescents (17), and another study
found the prevalence rate of 12.7% among children and
adolescents in Qatar (11). Overall, this high prevalence
of social phobia among Iranian children and
adolescents needs to be considered .
In spite of seven studies reporting the specific phobia
of less than 1% (13, 45), three researches found the
prevalence rates of 2.5% to 7.9%, and two studies
showed specific phobia greater than 20% (11, 12, 16).
The present review reported two Iranian studies with
the prevalence rates of 1.6% and 3% for specific
phobia (34, 35), and one Iranian research with the
prevalence of 18% for fear of physical injury (19) .
Thus, our findings are almost in line with some past
studies.
One Iranian study reported the prevalence rate of 1%
for panic disorder and 1.2% for agoraphobia (34),
which were slightly higher than two studies reporting
the prevalence rates of less than 0.5% for panic
disorder and agoraphobia (45). However, the Nigerian
study showed the prevalence of 2.4% for panic disorder
(16), and another study found the prevalence of 8.6%
for agoraphobia in Qatar (11). Also, one Iranian study
showed the prevalence rate of 12.2% for panic disorder
in Gorgan, which needs to be studied (19) .
Many studies reported the prevalence rates of dental
anxiety among children and adolescents; for example,
14.5%, 7.1%, 18%, 20.6% of Turkish, Scottish,
Brazilian and Taiwanese children and adolescents
experienced dental anxiety (46-49); however, one
Iranian research showed dental anxiety with a
prevalence rate of 9.34% in Shahrekord (39).
While one study reported selective mutism to be 0.18%
among Irish children (10), we did not find any Iranian
study to evaluate selective mutism. Since the
prevalence rates of PTSD were indicated in special
Iranian populations under special incidents, they were
excluded .
Across the included studies, anxiety disorders were
almost twice as common among females as compared
to males, and this finding is in line with that of other
studies (2, 50).
Limitations
We have only explored Persian and English databases
for peer reviewed articles and did not use gray
literature in our review. This issue can have an effect
on the reliability of our findings. Future review with
considering more sources of data may lead to more
precise results. In addition, we had no access to ISI
database in our country.
Conclusion
Our findings showed considerable amount of anxiety
disorder among Iranian children and adolescents.
Given that anxiety disorders have negative effects on
the well-being and function of individuals and can lead
to severe problems, they should be seriously considered
in mental health programs provided for children and
adolescents. Cognitive behavioral treatments may be
used to reduce anxiety disorders among children and
adolescents.
Zarafshan, Mohammadi, Salmanian
Iranian J Psychiatry 10:1, Jan 2015 ijps.tums.ac.ir 6
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